Willingnessto Use Telehealth IntroductionChronicobstructive pulmonary disease (COPD) is one of the major causes of morbidityand mortality across the world 1. Pulmonary rehabilitation is recommended as part ofthe treatment plan for COPD patients as it has been shown to improve functionality,and quality of life 2.

Pulmonary rehabilitation can reduce the cost ofhealth care by stabilizing or reversing systemic manifestation of the disease 3, and by reducingemergency visits and days of admission for COPD patients 4. However, only 1-2 % of COPD patients receivepulmonary rehabilitation services each year, despite its well-documentedbenefits 5. Reasons for such low utilization rate include pooraccess to a rehabilitation program and inconvenient timing of the program’sservices. Recently, tele-pulmonary rehabilitation, pulmonary rehabilitationservices through Internet, has been proposed as a solution for the currentproblems of shortages in rehabilitation programs, low attendance rates amongCOPD patients, and the high cost of the traditional methods of deliveringpulmonary rehabilitation services 6. Using telehealth in pulmonaryrehabilitation is in its infancy.

This situation highlights the need toelucidate the intentions of potential users for this technology to identifyinfluencing factors on the level of telehealth adoption in rehabilitationprograms. The identification of users’ acceptance level of telehealth could beof help to guarantee successful implementation, and positive outcomes offorthcoming tele-pulmonary rehabilitation programs.   Chronic Pulmonary Diseases andPulmonary RehabilitationIn the United States, chronicrespiratory diseases became the third leading cause of death in 2011 7.

COPD can be defined as “a preventable andtreatable disease with some signi?cant extra pulmonary effects that maycontribute to the severity in individual patients. Its pulmonary component ischaracterized by air?ow limitation that is not fully reversible. This air?ow limitationis usually progressive and associated with an abnormal in?ammatory response ofthe lungs to noxious particles or gases” 8. The number of newly diagnosed patients with COPDis increasing as approximately 14 million cases of bronchitis and 2 millioncases of emphysema have been reported every year 9. Based on the increasing number of patients withchronic pulmonary diseases and its consequences of individuals’ lives and onhealth care system in general, there is more attention now toward recommendingpulmonary rehabilitation interventions to be part of any treatment plan forpatients with chronic pulmonary diseases. Pulmonary rehabilitation is amultidisciplinary intervention that includes disease related education,cardiopulmonary and muscle strengthening exercises, and psychological supportdesigned to minimize disease symptoms and complications and to improveindividuals’ respiratory systems’ ability to function 10. Benefits of pulmonaryrehabilitation include optimizing functional status of the respiratory systemsand improving the quality of life in the four health-related quality of lifedomains: dyspnea, fatigue, mental health and mastery over the disease 2. Pulmonary rehabilitation can reduce health-carecost by stabilizing or reversing systemic effects of the disease 3, and by reducingemergency visits and days of admission for COPD patients 4.

Pulmonary rehabilitation services (PRS) can beoffered as in-patient hospital-based 11, or community-based out-patientprograms in-a group setting lasting usually for 8 to 12 weeks. Self-monitored,home-based pulmonary rehabilitation is an alternative method that can be moreconvenient, accessible, and cost-effective to deliver PRS compared toin-patient programs 12 13.Only 1-2 % of COPDpatients receive PR services each year, despite the well-documented benefits.Reasons for such low utilization rate include: poor access to a rehabilitationprogram, lack of transportation, and inconvenient timing of the program 5. Moreover, 34% of COPD patients who were referredfor pulmonary rehabilitation declined participation, and 36% were considered tobe non-adherent 14.

Aiming to improve patients’participation and adherence to pulmonary rehabilitation programs, additionaltools such as using Internet and telecommunication technology to supervisepatients at home just recently proposed. Remote real-time supervision usingtelecommunication technology during home-based pulmonary rehabilitationsessions has the potential to minimize patients’ anxiety during home exercisingsessions, provide accurate exercise prescriptions and aid patients’ recoveryprogression 15.    Telehealth Tele is Greek for “at a distance,” sotelehealth is the provision of health care at a distance 16. Telehealth defined asthe “use of electronic information and telecommunication technology to supportlong-distance clinical health care, patients, and professional health-relatededucation, public health and health administration.”17 Telehealth technology has beenused successfully in different health care disciplines including: pathology,radiology, psychiatry and dermatology, in addition to using telehealth toprovide home care or self-monitoring for patients with chronic diseases 18. According to The AmericanAssociation of Cardiovascular and Pulmonary Rehabilitation (AACVPR), telehealthtechnology can be used also to advance the delivery of cardiac and PRS. Telehealthtechnology can be used in rehabilitation programs as an adjunct to an existingtherapeutic modality, a method to improve the time frame of therapeuticcontact, or as an alternative tool when access to care is not available 19.

TechnologyAcceptanceTechnology acceptance can bedefined as the willingness of a user or a group of users to use informationtechnology that support their performance 20. Even though users’ actualadoption may not match their intention to use the information technology,measurements of technology acceptance can give the closest available predictionof actual technology usage in the future. In the past, technology developersand innovators relied on their authority to attract users to their products.

However, the availability of such technology alone did not motivate utilizationby patients. The pervasive expansion of information technology into everyaspect of life, in addition to the high cost of implementing new informationaltechnology systems, encouraged stakeholders in the health care system to seek moreunderstanding of the factors that would make their products more acceptable 20.Statement of ProblemUsing telehealth is a new field of health care practice.  Potential users’ uncertainty andmisperceptions regarding telehealth are barriers to its implementation 21.  Tosuccessfully establish a new telehealth program, the human factor must be accounted for as well as software andtechnology aspects.  Therefore, tosuccessfully implement a telerehabilitation program, level of acceptance needto be assessed among potential users. Measuring telehealth acceptancedeterminants will help telehealth developers design better systems thatconsider patients’ and health care practitioners’ needs.  Purpose This study aims to measure health care practitioners andpatients’ willingness to use telehealth.

The prime objective of conducting theresearch is to answer the following question: What is the acceptance (intention) level of using telehealthamong health care practitioners in comparison to patients?MethodologyThe data collection method for this study was aself-administered survey. The collected data involved measurement of theintention to use telehealth  Participants          Sample 1: thefirst sample included health care practitioners working in rehabilitationprograms.  A convenience sample was recruited for participation from rehabilitationprograms.  Participants were eligible ifthey: 1) read and write in English, and 2) health care practitioners working ina rehabilitation center.  This group ofparticipants included all the health care professionals (physicians, nurses,physical therapists, respiratory therapists, and occupational therapists) whoare involved or have participated in providing traditional face-to-face PRservices. Sample 2: this sampleincluded patients with respiratory conditions attending rehabilitationprograms.

  A convenience sample was recruited for participation from the rehabilitationprograms. Participants were consideredeligible if they: 1) read and write in English, 2) are older than 18 years, and3) are having a respiratory condition. This group of participants included all the patients with respiratoryconditions including patients with COPD, asthma, CF, bronchiectasis, andKyphoscoliosis who are attending PR programs.

 Patients with respiratorydeficiency or who underwent lung transplantation were also included in this study.StatisticalanalysisDescriptivestatistics (univariate descriptive) were performed to report thecharacteristics of the sample, to identify means and standard deviations.The hypothesis of this study was:patients have more intention to use telehealth in comparison with healthcareprofessionals. Independent T- test was conducted to test the hypothesis (table1) Table (1)ResultsCharacteristics of theparticipants.         Sample 1: this sampleincluded health care practitioners working in rehabilitation   programs. The sample included physicians, nurses, respiratory therapists,physiotherapists, occupational therapists, and exercise physiologists.

A totalof 222 subjects completed the survey.                                          The second sample in this study includedpatients with chronic respiratory diseases. A total of 134 subjects fromrehabilitation programs completed the survey. None of the participants in thissample have used telehealth.

  Hypothesis TestingTo test the null hypothesis thatthere is no difference between the groups; professional’s scores and patients’scores an independent t-test was conducted using a sample of 222 of healthcareprofessionals and 135 for patients. Since that the Sig value for Levene’s is lessthan 0.05 (0.

001), then we reject the null hypothesis that the variances of thetwo samples are equal. That is, we do not assume equal variances.Themean of the number of the scores of the healthcare professionals was 2.9 with astandard deviation (.69) and 2.

66 with a standard deviation of (.80) for thepatients group. The independent t-test showed that there was a statisticallysignificant difference between the two samples, t (355) =4, p=0.00, however,the effect size is small (r2 = 0.04).

This indicates that 0.4% of the variancein scores can be attributed to wither healthcare professionals or patients.These results suggest that healthcare professionals may have more intentionthan patients to use telehealth.Discussion        Measuring telehealth acceptance of onegroup of the potential users may provide a fragmentary picture of the situationand partial road plan for future telehealth programs, which in return mayaffect telehealth program outcomes and sustainability.  We sought to explore both health carepractitioners’ and patients’ perspectives on telehealth acceptance, which willbe useful in meeting their needs in future telehealth programs.  The involvement of patients, in addition tohealth care practitioners, in our study is in accordance with the increasinginterest of involving patients in health care decisions 22. Telehealthand telerehabilitation acceptance was measured in multiple studies 23-25.

Studies that explored telehealth acceptanceincluded different telehealth technologies. The definitions of telehealth varied from one study to another, but mostof the studies defined telehealth asthe general use of the Internet by health care practitioners to monitorpatients’ vital signs and exercise data.Telehealthacceptance among both health care practitioners and patients within the samecontext have not been explored to date. The literature includes one article similar to our research study.  Liu et al. (2015) utilized the unified theoryof acceptance and use of technology (UTAUT) to examine additional theoreticalfactors that affect acceptance of new technologies for rehabilitation bytherapists 26. Liu and colleagues measuredonly the health care practitioners’ acceptance of telerehabilitation.  In our study we measured telehealthacceptance of both patients and health care practitioners, which providedbetter understanding of telehealth acceptance.

A recent study explored the technology engagement level ofpeople attending PR and its effect on their intention to use telehealth 27.  Seidman and colleagues assessed theparticipants’ demographics associated with the willingness to use telehealth.  Even though the main goal of Seidman et al.’sstudy was to only assess the level of technology engagement and its effect onthe intention to use telehealth, it is a key study that examined how the demographicsof patients with chronic respiratorydiseases might affect their intentions to use telerehabilitation. Our findingthat the intention to use telehealth for patients is less could be  due to their old age and less exposer totechnology in comparison to the healthcare professionals where they use hightech machines and computers on their daily basis, further research is needed tosupport our findings.

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