As the third leading cause of morbidity and mortality worldwide, chronic obstructive pulmonary disease (COPD) is a significant public health issue [1-4]. In 2019, the number of individuals diagnosed with COPD exceeded 328 million worldwide [5-8]. A significant correlation between physical activity and lung function [9-12] emphasizes the importance of regular exercise for individuals with COPD who require pulmonary rehabilitation (PR) [13-19]. However, patients with COPD often report reluctance to engage in physical activities due to dyspnea, the effects of which include chronic cough, exacerbations, reduced exercise capacity, and impaired quality of life [20-25]. PR is a tailored and comprehensive intervention conducted via a thorough assessment of the patient. In individuals with chronic pulmonary diseases, the primary objective of the pulmonary intervention is to improve not only their overall health but also their psychosocial well-being in the long term [26-28]. Typically, PR programs are customized for personal symptomatic conditions [29-31]; hence, PR interventions entail tailored exercises and educational sessions aimed at enhancing activity tolerance, mitigating symptoms, and augmenting skills that aid in managing chronic respiratory diseases [31,32]. The majority of PR treatments usually require one-on-one sessions and the assistance of a therapist [33-35]. However, the one-on-one care approach is limited due to shortages in health care personnel, elevated work-related stress, and prolonged working hours [36]. Moreover, when the COVID-19 pandemic hit, lockdowns and personnel restrictions forced the interruption of PR for many patients with chronic lung disease, which posed a threat to their lives [37-40].

Due to the COVID-19 pandemic, telehealth has become increasingly attractive owing to its functionality, importance, and prospects [41,42]. In addition to reducing human contact and easing the burden on health care workers, telehealth leverages technology communication and transmission to alleviate the workload of respiratory therapists and improve the accuracy of respiratory rehabilitation records [43-45]. Using telehealth, patients can undergo rehabilitation at home and be monitored remotely by medical personnel [46,47]. Home-based PR can also mitigate the difficulties of outpatient care for patients living in remote areas and those with physical disabilities [48-50]. Furthermore, it can be used as an auxiliary means of physical PR to assist in self-management and precisely modify behavior, thereby reducing hospitalization and medical costs [51,52].

Traditional PR usually relies on one-on-one human monitoring through observation or physiological monitors to examine a patient’s health condition. Remote health care has the advantage of prescribing home-based PR, enabling patients who are unable to leave their homes due to physical conditions such as disability or living in rural areas to partake in rehabilitation programs at home [53,54]. However, there are also many limitations and considerations of remote health care, as follows:

Despite its limitations and by taking people, object, and environment into consideration, telemedicine remains a valuable tool for the provision of health care services, especially for patients who have difficulty visiting medical facilities in person or those affected by infectious diseases and related restrictions such as lockdowns and quarantine. Telemedicine enables uninterrupted treatment and continued assistance for patients in their recovery. However, in establishing a home-based PR, it is essential to consider the various environments of participants to effectively maximize the benefits of this medical service.

This study explores the perspectives and barriers of respiratory health care professionals and patients toward telehealth for rehabilitation for respiratory diseases. Based on the participant interviews, the use of home-based telerehabilitation for patients with lung diseases was perceived to have both advantages and disadvantages, which could be categorized under 4 domains: location, digital technology, internet connectivity, and physical space requirements. Unlike previous research [69], we adopted the people-object-environment framework and interviewed patients as well as health care professionals, with the aim of obtaining feedback from all participants in the same context. The 4 aspects mentioned above were found to be the most important concerns for health care institutions and patients.

Previous studies have reported that distance to outpatient care has a profound impact on chronic patients; in other words, the farther away from home, the lower is a patient’s willingness to seek medical care [70]. However, Bhatt et al [71,72] highlighted that patients often exhibit a reluctance to engage in PR, regardless of proximity, for several reasons. Both groups of interviewees in our study reported that the provision of alternative options would reduce the number of hospital visits, which would benefit patients and health care institutions. Although digital health care has its limitations, leveraging the internet to expand regional hospital services is not only beneficial to the public but also makes medical services more effective [73]. In special circumstances such as the outbreak of a pandemic, issues such as patients being unable to attend in-person treatments cannot be ignored. It is undeniable that digital health care, in particular, spawns numerous benefits in such situations. However, there are still limitations to digital health care for people (doctors or the public), equipment and network, and the environment (urban or rural). For example, most older patients feel that only consultations in person with doctors generate the feeling of being treated. Furthermore, without physical examinations, it could be difficult for doctors to diagnose the cause of symptoms. Nonetheless, digital technology remains a good choice for patients with respiratory disease who do not want to venture outside or exercise; however, not every patient’s home is equipped with remote medical devices or equipment, especially in rural areas [74]. Most patients with respiratory disease are also older, and without caregiver assistance, operating such devices can be difficult. In addition, due to limited professional knowledge, equipment, network, and living space, home care cannot replace all hospital diagnoses and rehabilitation. Therefore, in consideration of the findings from our study and a previous study [75], the implementation of hierarchical medical care requires that patients first undergo video consultations and then be referred to nearby medical institutions for appropriate treatment based on the severity of their condition. Patients can be referred to a larger medical center when necessary for treatment through an electronic referral platform between institutions. This approach not only effectively improves the utilization efficiency of medical resources but also significantly reduces medical expenses and transportation costs for patients.

This study has some limitations. First, as our study was conducted in a specific health care institution, our findings may not be generalizable to other regions or institutions. Second, most patients had poor health conditions and no prior experience with PR; thus, they relied only on limited experience and information. Lastly, the majority of the participants were older, which may have influenced their responses regarding computer use or internet issues. Additionally, health care service needs likely vary between urban and rural areas, and our study does not distinguish between the challenges and differences in home-based PR between these 2 types of areas. Future research should consider this aspect in their study design.

Most study participants reported that telehealth could greatly benefit patients with chronic pulmonary diseases; however, these benefits were not without limitations. Reflections on these limitations by patients or health care professionals revealed that telehealth is not suitable for all patients. For example, diagnosis and treatment via telehealth can only accomplish certain tasks and merely serve as a tool for preliminary diagnostic assessments. Nonetheless, preliminary assessments can determine whether a referral to a regional hospital or a large teaching hospital is necessary. This classification and referral system will also be applicable to rehabilitation therapy. Not all patients are suitable for home-based PR, considering patient safety, the required space and equipment, or the need for further precision testing, among other factors. In addition, although telehealth brought many conveniences to patients and health care professionals, both parties still faced significant psychological pressure. Patients noted that digital medicine lacked warmth, and they tended to prefer human care, while physicians had doubts about medical decision-making without the ability to perform physical examinations. The degree of control over digital technology was also an issue. Both parties lacked confidence that effective treatment could be achieved solely through the internet. Even though digital care has the advantage of long-term patient monitoring, some patients were unfamiliar with internet devices, and health care professionals were concerned that patients may not always respond correctly to instructions. Moreover, patients often neglect their physician’s advice (such as following prescribed exercise schedules) due to lack of motivation and the need to physically meet with the physician. Both groups of study participants indicated that significant improvements in telerehabilitation technology were still needed, particularly for patients in rural areas or those who were older and living alone, who require more support and services.