Table 2.

Summary of system improvements.

Issue			Modification
Physical/environmental
	Patients that have low motor and upper body strength have trouble adjusting the bike seat to a level of comfort and the tablet to eye level.	Prior to the encounter, the respiratory therapist will need to advise patients to adjust the angle of the tablet and the seat position to the most advantageous comfort level. In certain patients, the study team member will need to be present to adjust the seat.
	Tablet mounting arm is too short and may cause neck strain for certain patients.	Tablet mounting should be on a longer arm stand to prevent patient neck strain when viewing the tablet, riding the bike, and completing other exercises during the session.
	The lack of a standardized approach to each telePRa session leads to patient dependency.	The respiratory therapist should present a checklist to the patient prior to the encounter to check items (such as the seat, tablet, water, oxygen, weights, phone, etc) so that the patients may become independent during subsequent sessions.
Safety
	Emergencies that occur during the encounter must be addressed.	Develop a standard of operations for patient emergencies that may occur during the telehealth visit.
	Wi-Fi may be lost during the telePR session.	Handouts should be available with directions for patients to answer the phone or to call the respiratory therapist if Wi-Fi is lost.
	Patients that have knee problems may have trouble completing the telePR session.	Consider mobility criteria prior to a patient’s enrollment in the study (eg, patients who have had a recent knee surgery may encounter difficulties riding a bike).
Technology
	Bandwidth issues cause considerable interruptions throughout the session.	An initial technical assessment is needed at each site to ensure that Wi-Fi is sufficient to support telehealth technology. If issues continue to arise, then a research study member should be present at a particular site to address them.
	Audio problems may occur during a telePR session.	In case of audio problems during teleconferencing, the patient’s cell phone number should be provided to the respiratory therapist to call if the teleconference goes down.
	The Windows software has small close (X) icons that are not ideal for patients with large fingers, arthritis, or visual impairment to exit screens.	For users in the Dependent category, the technical demands required to configure and use the tablet hardware, software, and the associated devices are too tedious for a successful experience; these patients require a study team member to be present at the telePR session.

^atelePR: telehealth-delivered pulmonary rehabilitation.