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Exercise is Medicine® — 10 Years and Counting: Looking Back, Moving Forward

Thompson, Walter R. Ph.D., FACSM; Hutber, Adrian Ph.D.; Stoutenberg, Mark Ph.D., MSPH

doi: 10.1249/FIT.0000000000000334
Departments: Health and Fitness A to Z
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Walter R. Thompson, Ph.D., FACSM,is associate dean for Graduate Studies and Research in the College of Education & Human Development at Georgia State University and a regents’ professor in the Department of Kinesiology and Health, the Department of Nutrition, and the School of Public Health. He also is the executive director of After-School All-Stars Atlanta. He is currently serving as the ACSM President.

Adrian Hutber, Ph.D.,is the senior adviser of Exercise is Medicine® (EIM). Before joining EIM, Dr. Hutber was the director of the Distance Education Division of Human Kinetics.

Mark Stoutenberg, Ph.D., MSPH,is a voluntary faculty member in the Department of Public Health Sciences at the University of Miami and a program officer with the Exercise is Medicine® initiative. Dr. Stoutenberg’s research focuses on developing referral schemes to connect patients from health care systems to available resources for physical activity in community settings.

Disclosure:The authors declare no conflict of interest and do not have any financial disclosures.

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The Early Years

In 2007, Robert E. Sallis, M.D., FACSM, became the 51st President of the American College of Sports Medicine (ACSM). Like his predecessors, Dr. Sallis was determined to leave behind a lasting presidential legacy — one that would not only endure, but would be embraced over time by ACSM members. The Exercise is Medicine® (EIM) initiative was born during Dr. Sallis’ tenure, through his hard work and determination, and has since enjoyed unimaginable success over its first decade. However, this success was neither quick nor immediately apparent. EIM and ACSM needed a substantive partner to help garner attention and announce the arrival of EIM on the national public health landscape. In October 2008 that partner emerged, as the American Medical Association and its President, Ronald M. Davis, M.D., joined Dr. Sallis and ACSM on the steps of the National Press Club in Washington, DC, to announce the launch of EIM. In the decade since, EIM has received the support of numerous other national and international partners.

The original purpose of EIM was to make physical activity part of the treatment plan medical doctors used with their patients. Initially, this proved to be difficult because it was not standard practice for physicians to counsel patients on their physical activity habits. However, the evidence supporting the benefits of physical activity has grown to such an extent and become so overwhelming (3), physicians all over the world have taken notice and have begun talking to their patients about becoming more physically active. With the multicultural appeal and portability of EIM, leaders from around the world approached ACSM about joining EIM and developing similar initiatives in their own countries. Within 2 years of its U.S. launch, ACSM realized an opportunity to expand the reach of EIM beyond the United States and committed to making it an international effort. The EIM Global Health Network, headquartered at the ACSM National Center in Indianapolis, IN, now has a presence in more than 43 countries, clustered in 7 regions around the world.

Like any new idea or program, EIM faced some initial barriers. The first obstacle was to convince busy physicians that they could find the time in their patient assessments to include questions related to physical activity. In 2007, most physicians were using paper files, as electronic medical records (EMRs) either did not exist or were just being introduced into their clinical practice. Since that time, the EMR has become standard practice, with many now including questions about patient’s physical activity habits.

A second obstacle EIM faced was providing the necessary tools and information to assist physicians in answering the inevitable questions patients had about what kinds of physical activity were most appropriate for them (i.e., the FITT-PP principle; frequency, intensity, time, type, pattern, and progression). The remedy was to make available to clinicians a series of patient-oriented materials on physical activity. The EIM Prescription for Health series (4) gives health care teams the ability to provide their patients with customized exercise guidance (i.e., disease-specific exercise recommendations and contraindications) based on their specific disease condition. These materials can be further used by exercise professionals in individualizing their exercise prescription for individuals with medical conditions. Furthermore, the development of an EIM prescription pad allows providers to give their patients a quick and simple written exercise prescription consisting of recommendations for daily aerobic activity, desired daily step counts, and weekly strength training recommendations.

A third obstacle that physicians faced was questions from their patients about who in their community could best help them with their exercise program. This barrier remains a challenge today, but with the recent creation of the EIM Credential (2) and the U.S. Registry of Exercise Professionals (5), which are both developed and supported by notable fitness professional certifications, it is now easier to find trustworthy and certified exercise professionals in any community. Additional efforts are underway to develop and catalog “networks” of EIM certified resources in communities across the country.

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Transitioning to a Second Phase — Gaining Traction in U.S. Health Care Systems

By 2011, it had become apparent that EIM was rapidly gaining traction and destined to become a highly successful health initiative. Similar to many other health and wellness campaigns, EIM’s initial successes were in building awareness and soliciting widespread support and commitment from the global community. At this point, EIM began shifting into a second phase, with a focus on creating transformational change by working to make physical activity a standard in health care and connecting patients from health systems to their local community resources.

In 2015, the EIM Global Center began a first-of-its-kind, joint collaboration with the Greenville Health System (Greenville, SC). Greenville Health, a forward-thinking health care system, was launching a new medical school and had developed strong partnerships throughout its community, including the local YMCAs. This triumvirate provided EIM with the perfect opportunity to pilot test the EIM Solution, the pragmatic application of EIM in a health system. The first step of the EIM Solution is based on the demonstrated success of integrating a physical activity vital sign (PAVS) in the EMR, as first piloted by Kaiser Permanente (California) and Intermountain Health (Utah). Greenville Health integrated the PAVS in its EMR to screen for physically inactive patients, who are then referred to one of the Greenville YMCAs to participate in group-based physical activity interventions led by EIM Credentialed exercise professionals. The collaboration between the EIM Global Center, Greenville Health, and the city of Greenville has proven to be such a successful model that a growing list of health care systems and community partners have expressed interest in exploring a collaboration with EIM similar to the initial pilot in Greenville.

In addition to the growing number of health systems seeking to implement the EIM Solution, several county health departments, federally qualified health centers, and community free clinics have begun adopting components of the EIM Solution to increase physical activity promotion in low-resource communities. These grassroots efforts include adapting EIM materials for their local sociocultural context, working with community health centers on adopting components of the EIM Solution (i.e., assessing physical activity levels) in their patient care process, and providing physical activity training workshops for their health care teams. These efforts also involve developing networks of free and low-cost physical activity programs, places, and professionals in the county, engaging the staff at community health clinics in physical activity programs to highlight the importance and benefits of daily activity, and working with local exercise professionals to offer free programs for patients onsite at the health clinics.

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Rise of the EIM Credential

To support the growth of EIM in the communities served by these various health systems, there is a growing need to develop the community resources to support referred patients. Given the plethora of existing exercise professional certifications, as well as a lack of clarity regarding the quality of some of these certifications, a need arose to develop a system that would assure the health systems that their patients are being referred to the best-trained and most-qualified exercise professionals. The EIM Credential takes individuals with exercise certifications from any of 12 different National Commission for Certifying Agencies (NCCA) recognized organizations (1), as well as individuals with a bachelor’s or master’s degree in exercise science or a related field, and provides them with the education and skills to work with patients referred to them from health care systems and providers. The EIM Credential focuses on providing exercise professionals with the knowledge to work as an extended member of the health care team and the skills to use behavioral modification in working with patients with chronic disease conditions. To date, more than 1,500 individuals across the United States have earned the EIM Credential. As more health systems adopt and implement the EIM Solution, the demand for EIM Credentialed professionals will continue to grow exponentially because of a shortage of highly trained exercise professionals equipped to provide specialized care to the growing epidemic of individuals who are physically inactive, are overweight/obese, and have cardiometabolic diseases. In addition to working with ACSM certified individuals, EIM is partnering with organizations such as the American Council on Exercise and the Medical Fitness Association to rapidly expand the networks of EIM credentialed professionals in every community across the country.

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Engaging Our Next Generation of Leaders: EIM on Campus

In addition to advancements in U.S. health systems, EIM has enjoyed an equal amount of success in the community setting. One signature program, EIM on Campus, has experienced unparalleled growth in recent years. Today, there are more than 150 EIM on Campus programs throughout the United States. The university campus is a microcosm of our society, consisting of all major “sectors” necessary to implement the EIM Solution. Most campuses have some combination of student health centers, health clinics for faculty and staff, and hospitals, as well as a multitude of resources for physical activity (i.e., wellness centers, aquatic centers, athletic fields). Furthermore, many campuses have training programs for health professional fields (i.e., medicine, nursing, occupation, and physical therapy), as well as exercise science/kinesiology programs that produce highly skilled exercise professionals. The EIM on Campus program recognizes efforts to link students, staff, and faculty on a campus with the different physical activity resources and personnel. Attainment of “gold” level status requires implementing the PAVS in one of its health care settings and connecting patients to campus-based physical activity programs and exercise professionals.

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THE NEXT DECADE FOR EIM

To expand the reach of EIM to include health care providers not in health systems currently adopting the EIM Solution, partnerships are being pursued with multiple health professional organizations across a range of specialties and patient populations. Through collaboration with various physician, nursing, and other health care provider organizations, EIM seeks to share the benefits of physical activity, EIM tools and materials, and engages providers in taking the pledge to add physical activity as a part of their patient care process. Furthermore, EIM continues to work as a part of a collaborative effort to advocate to the National Committee for Quality Assurance for a Healthcare Effectiveness Data and Information Set (HEDIS) measure on physical activity for adults that mirror similar existing measures for children and older adults. The inclusion of an adult HEDIS measure on physical activity will incentivize health care systems and providers to engage their patients in discussions on physical activity, leading to greater counseling efforts, and potential opportunities for referral to EIM Credentialed professionals and programs in the community setting.

As EIM evolves to meet the health care challenges faced in the United States and around the world, there is a need to constantly align with the rapid changes happening in our health care system. To this end, a revision of the EIM Credential is currently underway to ensure that exercise professionals are being presented with the latest information on working with health care systems and individuals with disease conditions in an interactive, applied learning model. Efforts also are underway to develop a quality control system to ensure that EIM-related programs offered in community settings meet certain quality standards and the needs of the referring health care system.

As EIM evolves to meet the health care challenges faced in the United States and around the world, there is a need to constantly align with the rapid changes happening in our health care system. To this end, a revision of the EIM Credential is currently underway to ensure that exercise professionals are being presented with the latest information on working with health care systems and individuals with disease conditions in an interactive, applied learning model. Efforts also are underway to develop a quality control system to ensure that EIM-related programs offered in community settings meet certain quality standards and the needs of the referring health care system.

Finally, the integration of technology within clinic and community settings will have a major impact on the future success of EIM in increasing patient physical activity levels. Mobile health (mHealth) applications and wearable activity monitors provide an opportunity to advance the assessment and integration of physical activity counseling in clinical settings. The use of mHealth technology for cardiovascular disease risk reduction has shown promise; however, it has proven challenging to institutionalize its use in routine clinical care. Challenges experienced include issues of patient privacy and security, error in the assessment of physical activity, and reporting of physical activity data in a manner that is applicable and practical for routine meaningful use (i.e., linking data from wearable monitors directly to EMRs). Beyond these issues, health care providers will be able to use wearable technology and apps to connect their patients to community-based physical activity resources. In the community setting, exercise professionals can use wearable monitors to provide more accurate feedback on their client’s progress and use this information to tailor behavior change programs. Furthermore, wearable devices will be essential in connecting patients, exercise professionals, and health care teams in a full circle of communication.

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SUMMARY

As U.S. health care continues its transition from volume- to value-based care, EIM has a unique opportunity to be a major contributor and position itself as the primary resource for physical activity by linking clinical settings with community care, with a large EIM Credentialed work force providing a key component of this connection. Looking into the future, EIM strives to develop and maintain partnership with a majority of U.S. health systems to connect patients to a multitude of self- and professionally guided physical activity interventions for the treatment and prevention of a large number of chronic diseases, including hypertension, type 2 diabetes, cardiovascular risk factors, and many more. In addition to partnering with major U.S. health systems, the EIM Global Center strives to continually develop new clinic tools to aid health care providers in integrating physical activity in their health system, as well as tools that allow exercise professionals to better work with patients as an extended member of the health care team. Finally, and perhaps most importantly, EIM simultaneously seeks to reduce physical activity-related health inequities by partnering with low-resource health settings to bring affordable, low-cost physical activity options to low-income communities.

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References

1. American College of Sports Medicine. ACSM Certification. Accredited Certifications. [cited August 3, 2017]. Available from: https://certification.acsm.org/exercise-is-medicine-accredited-certifications.
2. American College of Sports Medicine. ACSM Certification. Exercise is Medicine Credential. [cited August 3, 2017]. Available from: https://certification.acsm.org/exercise-is-medicine-credential.
3. Centers for Disease Control and Prevention. Physical Activity and Health. [cited August 3, 2017]. Available from: https://www.cdc.gov/physicalactivity/basics/pa-health/index.htm.
4. Exercise is Medicine. Your Rx for Health Series. [cited August 3, 2017]. Available from: https://exerciseismedicine.org/support_page.php/your-rx-for-health-series.
5. United States Registry of Exercise Professionals®. [cited August 3, 2017]. Available from: https://www.usreps.org.
© 2017 American College of Sports Medicine.