A team from Northern Sydney Local Health District (NSLHD) has developed the first Australian mobile health pulmonary rehabilitation program – a home-based model via a smartphone app.
Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. COPD is also a major contributor to health inequity, as Aboriginal people experience higher rates of chronic respiratory disease and barriers to care.
Pulmonary rehabilitation is a best-practice, evidence-based intervention that improves exercise capacity, COPD symptoms and patient quality of life while reducing healthcare costs. It combines tailored exercise training, education and behaviour change strategies following comprehensive patient assessment. To improve access to pulmonary rehabilitation, we developed m-PR™, Australia’s first mobile health pulmonary rehabilitation program, delivering a comprehensive, home-based model via a smartphone app.
Addressing systemic barriers to care
In 2018, we brought together a team of NSW clinicians, academics and technology experts to address persistent barriers to pulmonary rehabilitation access. International groups had started investigating mobile health pulmonary rehabilitation programs in 2015. The UK National Institute for Health and Care Excellence now recommends these programs as standard clinical practice when centre-based pulmonary rehabilitation is not available.
The need for innovation was clear; despite pulmonary rehabilitation being a gold-standard intervention for COPD, uptake and completion rates remained low. Patients faced significant challenges including travel distance, transport costs, rigid scheduling and comorbidities, leading to missed opportunities for symptom improvement and increased risk of hospitalisation.
For staff, these barriers resulted in inefficient use of resources, repeated referrals and frustration when patients could not attend programs. At a system level, poor pulmonary rehabilitation access contributes to higher healthcare costs through preventable exacerbations and hospital admissions.
Co-designed with consumers, m-PR integrates exercise training, education, symptom monitoring and behaviour change, supported by clinician oversight. Since inception, the project has undergone iterative development, user testing and a multicentre randomised controlled trial demonstrating safety, high acceptability and adherence, and equivalent or superior outcomes compared to centre-based pulmonary rehabilitation.
By enabling flexible, home-based rehabilitation, m-PR:
- reduces systemic barriers
- empowers patients in self-management
- alleviates pressure on overstretched health services.
Implementation includes user testing, clinical evaluation and scale-up
The development of m-PR has included four phases, from co-design and development through to user testing, a randomised controlled trial and implementation.
Phase 1: Co-design and development (2018–2020)
We partnered with consumers to co-design m-PR, ensuring usability and cultural relevance. The app incorporated all essential pulmonary rehabilitation components – exercise training, education, symptom monitoring, and behaviour change – supported by clinician oversight.
Phase 2: User testing and refinement (2020–2022)
We conducted usability and acceptability testing with patients to refine app content and features, and improve navigation, educational content and exercise tracking.
Phase 3: Clinical evaluation (2022–2024)
We conducted a multicentre, randomised controlled trial comparing m-PR with centre-based pulmonary rehabilitation. We successfully demonstrated safety, high adherence and equivalent improvements in exercise capacity, with superior health status outcomes for m-PR participants. Alongside this, a qualitative evaluation confirmed consumer acceptability and identified motivators such as flexibility and convenience. We also undertook a cost and greenhouse gas emissions analysis, which demonstrated that if implemented in clinical practice m-PR would be cheaper to deliver and result in lower carbon emissions compared to centre-based programs.
Phase 4: Implementation and scale-up (2024–present)
To enable scalability and sustainability, we explored different pathways. Firstly we transferred m-PR content onto a commercial platform through a partnership with Perx Health, which operates an evidence-based chronic disease management app built on behavioural science principles. Perx has demonstrated clinical efficacy in improving medication adherence and health outcomes in chronic disease populations with initial user testing of m-PR on the Perx platform demonstrating acceptability. Commercialisation supports scalability and sustainability of the platform, beyond a research setting.
m-PR on the Perx platform, is now being trialled across pulmonary rehabilitation programs in NSLHD – we are evaluating implementation through a mixed method, hybrid implementation effectiveness study. Early clinician engagement has demonstrated high perceived acceptability and appropriateness, with moderate to high feasibility for integration of the platform into real world clinical settings. Clinician training, clear workflows, and defined patient inclusion criteria will be important factors to facilitate successful adoption.
Additionally, we have planned a further Translational Research Grant (TRGs) application to support scale and spread, in partnership with our original software partner CSIRO, who now has the capability to integrate with SDPR, and are able to support scaling the m-PR program post-TRGs for roll-out across NSW.
Aboriginal and Torres Strait Islander people have not yet been involved in the identification or design stages of this project. The initial development of m-PR began in 2018, focusing on addressing widespread barriers to pulmonary rehabilitation access for the general population. We acknowledge the importance of culturally safe and tailored solutions and will now actively source funding to co-design an Aboriginal-specific version of m-PR in partnership with Aboriginal communities and health organisations. We aim to align the next phase with Closing the Gap and NSW Health Plan priorities following the expansion of m-PR to other LHDs, by promoting culturally responsive care, digital health equity, and chronic disease management for Aboriginal people in rural and remote areas.
Co-design in digital health ensures accessibility and user confidence
Throughout the design and implementation of this program, we have learnt valuable lessons that have allowed us to create a robust and accessible digital intervention that supports patients with COPD.
- Co-design and consumer engagement are critical. Early and meaningful consumer involvement was essential. Usability testing revealed that even small design changes, such as simplifying navigation and clarifying exercise instructions significantly improved engagement. This reinforced that digital health solutions must be co-designed to ensure accessibility, cultural relevance and user confidence.
- Flexibility drives adherence and outcomes. Our qualitative evaluation showed that flexibility and convenience were key motivators for adherence. Participants valued completing sessions at home and fitting rehabilitation around their schedules. This flexibility contributed to high adherence and superior health status outcomes compared to centre-based programs, as confirmed in our randomised controlled trial.
- Digital health is hard, and technology evolves rapidly. Implementing and scaling digital health requires robust infrastructure, executive endorsement implementation support and strategic partnerships. Our partnership with Perx Health, a proven behavioural science-based platform with strong clinical evidence, positions NSLHD as a leader in digitally enabled care. Scaling across NSW will deliver economies of scale and create a foundation for a whole-of-chronic-disease approach, with the potential to expand beyond COPD to other chronic respiratory conditions and multimorbidity. Without timely adoption, we risk missed opportunities to improve patient outcomes, reduce hospital readmissions, and maintain competitiveness. Digital transformation is essential for sustainability and alignment with NSLHD strategic priorities.
