In 2017, the “Exercise is Medicine” (EIM) campaign, an initiative started by the American College of Sports Medicine (ACSM), celebrated 10 yr of influence in advancing the integration of exercise into formalized medical care based on the breadth and depth of evidence for its utility across clinical populations (1–4). This international, interprofessional endeavor recommends the EIM “solution” for improving population health via the integration of exercise services into health care through strategic linkages between health care systems, providers, health-related digital technologies, and available exercise programs (exerciseismedicine.org). In practice, the “solution” is achieved via (i) the assessment and record of clients’ physical activity levels throughout their care embedded into the electronic medical record (EMR), (ii) prescribing exercise that is individualized to specific health conditions, and (iii) referral of clients to evidence-based exercise programs delivered by qualified exercise professionals (QEPs). Given the critical role of the EMR in health care communication, optimizing the use of the EMR is recognized as a key factor in achieving overall EIM ambitions.
Contemporary chronic disease management often includes a complex informatics infrastructure comprising accurate, complete, and legible documentation to facilitate the assessment of large and diverse data toward consistent care decisions and reporting (5,6). Consequently, usage of the EMR for communication across health care professionals is ubiquitous in the United States, Canada, and much of the developed world. Moreover, compared with paper records, the EMR reduces medical errors, improves the continuity of care, and can result in cost savings (5,6). The EMR, however, is rarely if ever used for communication between QEPs and other members of the clinical team because exercise professionals are not traditionally considered an integral part of clinical care teams. This compromises accessibility to exercise services and/or referral pathways to QEPs in institutions that have them.
The integration of exercise information, including referrals, assessments, prescriptions, and follow-ups, is valuable to the medical practitioner, QEP, and patient triad in several ways. First, by virtue of exercise’s inclusion into the EMR, it formally recognizes the evidence-based health benefits of exercise within the health care model, acknowledges the role of the QEP therein, and enhances the comprehensive nature of disease management strategies. Although not traditionally incorporated into the allied health team, QEPs with specialties, such as oncology, are ideal to ensure the effective and safe delivery of exercise programming. Second, the prevalence of exercise-related EMR notes increases awareness of programming across the clinical teams and may lead to increased interprofessional collaboration and referral rates for exercise programs. Lack of awareness for exercise programs is cited as a barrier to physical activity participation in patients (7,8) and can be, in part, overcome through increased visibility of appropriate programming across the entire health care team. Third, through acknowledgment of the benefits, relevant team members, and broader visibility, incorporating exercise documentation into the EMR may facilitate greater adoption of exercise behaviors in the institution’s chronic disease population to reduce the overall disease burden and health care system usage (1). Finally, communication within the EMR about patient issues that patients may not know or adequately recall allows for increased customization of the exercise prescription and enhances patient safety and program effectiveness.
In oncology, exercise is established as a fundamental element of comprehensive cancer care with convincing evidence of its benefits to physical and psychosocial well-being (9,10), and emerging evidence describes improved clinical outcomes such as recurrence and survival for those who are active (11–13). Unfortunately, most cancer survivors are insufficiently active to derive many of the benefits (14,15) with significant declines in physical activity after diagnosis (16–18). Current guidelines from the ACSM (19) as well as other national (20) and regional (10) cancer organizations recommend regular exercise after a cancer diagnosis and that many cancer survivors would benefit from the support of QEPs (i.e., equivalent to the EIM level 2 or 3 certification) with expertise in oncology. Moreover, research has shown that the physician plays an essential role in the exercise behaviors of their patients through recommendations, referrals, and as program champions (21–23). Accordingly, expedient, accessible, and comprehensive communication and/or referrals between oncologists and QEPs are needed to enhance cancer survivor access to quality exercise programming. This need underscores the EIM initiative of integration of exercise-related information and services directly into the health care system—an initiative that would be significantly advanced through the incorporation of exercise care information into the EMR. Integrating exercise information into the EMR requires a paradigm evolution in what constitutes both “standard of care” for cancer survivors and expertise considered part of the clinical team. Naturally, such an evolution has complex health care culture, administrative, clinical, and research implications and challenges but is warranted to advance evidence-based cancer care through the formal inclusion of exercise in disease management.
Implementation science focuses on understanding factors influencing implementation success and determining strategies best able to facilitate the implementation of evidence-based interventions (24). The Consolidated Framework for Implementation Research (CFIR) provides a structure for guiding implementation research by defining multiple constructs within five major domains: 1) intervention characteristics, 2) influences outside the implementing organization (outer setting), 3) organizational attributes (inner setting), 4) characteristics of individuals involved, and 5) process (e.g., planning, engaging, etc.) (25). Within these domains are predictors of implementation success that are being increasingly identified and labeled to advise and guide implementation strategies (26,27). To date, little is known about the implementation and use of exercise-related information in the EMR. Sharing early experiences in the use of the EMR connected to exercise programming can facilitate a better understanding of the facilitators, barriers, and opportunities in this important element of the EIM solution. In this article, we describe our implementation pathway to integrating exercise information in the EMR at three cancer centers in North America. Each center's narrative begins with a description of the center and follows with setting-specific opportunities and approaches for the use of the EMR in connecting people with cancer to exercise-based care. These experiences are then contextualized within the CFIR framework to provide targets for impact measurement and strategy consideration for similar endeavors.
Leveraging the EMR to Facilitate Exercise Integration into Clinical Care for Cancer Patients—Experiences at the University of Alabama at Birmingham
At the University of Alabama at Birmingham (UAB), the first effort to connect oncology care with QEPs occurred via the already established and institutionally supported UAB Weight Loss Medicine (WLM) clinic. Using the ongoing health system infrastructure and identified information technology (IT) staff, a mechanism was created allowing oncology health care providers to refer overweight and obese cancer survivors interested in weight loss to the clinic via the EMR’s standard referral processes. Once seen by the WLM physician, patients are assisted with identifying appropriate QEPs, primarily outside the EMR system. In this respect, the EMR facilitated the integration of exercise services for cancer survivors via the WLM clinic because resources for new, large-scale, cancer-specific initiatives were not available. The experiences reported here describe the integration of QEPs within the EMR system for providing safe and appropriate progressive exercise training and motivation for overweight or obese cancer patients.
In conjunction with needs for referral capability, it was necessary to build capacity for and access to QEPs with oncology expertise. Accordingly, several master’s trained exercise physiologists at UAB were certified as ACSM Cancer Exercise Trainers, and exercise sessions (individual and group) were made available on a fee-for-service basis (i.e., participants paid out of pocket, as insurance billing was not possible). Once capacity and programming were in place, local providers were made aware of the resource through presentations (e.g., grand rounds) and individual meetings with oncologists. Also, a champion was identified within the cancer center administration who was willing to assist in determining strategies for leveraging current infrastructure to increase awareness of exercise programming. As a result, a goal was set to integrate exercise into the broader oncology program by connecting patients to QEPs through the patient navigator system. This approach was more feasible because of the precedent set by allowing health care providers and navigators to communicate through the EMR. In anticipation of such capacity, work to establish exercise-related templates (exercise encounter and assessment data) was initiated for integration into the care management plan software with the long-term goal of providing feedback to the navigator and referring health care practitioners through integration of the care management plan software with the EMR.
The aforementioned experience suggests that existing cancer and non-cancer-specific programs linked by existing EMR infrastructure can be used to increase access to exercise resources. These strategies can be used as preliminary steps and do not require changes in institutional priorities or external policies that may be prohibitive.
Overcoming Barriers to Integrating Exercise into the EMR—Experiences at Sylvester Comprehensive Cancer Center
Within the Sylvester Comprehensive Cancer Center at the University of Miami, the Department of Oncology Support Services encompasses a multidisciplinary team of clinicians (psychiatrists, psychologists, dietitians, massage therapists, exercise physiologists, music therapists, acupuncturists, and social workers) focused on providing complementary care during and after cancer treatment to improve patient’s quality of life and symptom management. Within this team, QEPs provide individualized activity counseling to patients with the option of enrolling patients in an 8-wk supervised exercise program offered at the campus’ medical wellness center. Visits with the QEPs are provided as a complementary service to standard care and at no cost to the patient (i.e., costs covered by local cancer center). At the inception of exercise programming, referrals and exercise encounters occurred outside the EMR system using paper documentation.
In 2014, the UHealth system, including the Sylvester Comprehensive Cancer Center, launched an initiative to transfer all medical records across the institution to a new EMR system. The “Go-Live” initiative for UChart provided a unique opportunity to leverage the university and hospital-wide mandate to substantiate and prioritize the inclusion of Oncology Support services with the new EMR. The efforts to integrate QEPs within the EMR required intense collaboration with the UChart Go-Live team who were responsible for ensuring that the transition of each clinical service met the requirements set by hospital leadership and the Build Team, composed of software developers with the ability to modify the EMR. Two primary challenges arose early in the process. First, program QEPs were not initially considered credentialed or licensed health care providers and thus the Go-Live team provided “view-only” access inhibiting many of the features of the EMR that facilitate collaboration with the medical team. Part of this challenge was due to a fundamental lack of understanding as to what education and training our QEPs had and what clinical care is provided to the patient. All QEPs at the center were required to have at least a master’s degree and obtain a clinical certification from the ACSM. Thus, QEPs had to become unofficial ambassadors at the center, providing education and background on the EIM initiative and professional standards for the field, specifically highlighting scope of practice guidelines. As a result, QEPs were established as care providers and all QEP services were aggregated within the EMR under a clinical service department called Exercise Oncology. This allowed QEP staff to create their own clinical schedules, receive electronic referrals, and document clinical encounters in the EMR system. The determination of the level of access and permissions QEPs would have within the EMR proved critical to the success of the initiative.
The second challenge arose over discussion of how QEPs would document the clinical visit. There are no recognized exercise-related templates for use in an EMR, let alone anything cancer-specific. To develop appropriate exercise-oncology templates, QEPs met extensively with the Build Team to specify the requirements and metrics for documenting patient visits/care. The end product was a customized Exercise Oncology encounter with the following six key elements: (a) a detailed summary of medical history, including comorbidities and cancer treatments that may affect physical activity; (b) vitals and fitness-related metrics; (c) patient risk factor screening and assessment, including cardiovascular and musculoskeletal risks/contraindications; (d) the physical activity vital sign; (e) the patient’s current patient activity and summary of patient narrative (reason for visit, goals and barriers); and lastly, (f) the exercise prescription and plan for follow up (see Fig. 1 for Sylvester EMR template for Exercise Oncology).
The integration of Exercise Oncology into the EMR produced a marked increase in utilization of services by patients reflected by an increase in referrals to QEPs and expansion of services to satellite locations. Oncologists at the institution are now able to sign an order for “Referral to Exercise Oncology,” which is scheduled alongside other follow-up appointments at discharge from medical visits. Further, oncologists can note the reason for referral (e.g., deconditioning, weight management, loss of lean mass, etc.) and any contraindications or cautions for exercise directly in the order. Direct communication via messaging within the EMR enables the medical team to keep in contact with the QEP to monitor progress. Patients are able to easily see the upcoming Exercise Oncology appointment in the EMR patient portal and receive an exercise prescription within the After-Visit Summary documentation that further highlights the importance of the exercise recommendations and supports the goal of utilizing exercise as medicine.
Optimizing Exercise Information Entry into EMR for Clinical-Research Capacity—Experiences from the Princess Margaret Cancer Centre
Within the Department of Supportive Care and the Cancer Rehabilitation and Survivorship Program, an interprofessional team delivers an 8-wk Cancer Rehabilitation and Exercise program, known as CaRE. CaRE is free for patients and is accessed via a direct, paper-based referral pathway from attending oncologists at the Princess Margaret, followed by a comprehensive health and fitness assessment and an 8-wk exercise program. The 8-wk facility-based or at-home program includes weekly educational seminars (in-person or via e-modules) related to prevalent cancer survivorship issues, such as diet, stress management, return to work, etc. Eligible participants are those that have been treated within the institution and require rehabilitation-based care for active cancer-related impairments (e.g., shoulder dysfunction postmastectomy, cancer-related fatigue, lymphedema, systemic and/or localized deconditioning, etc.), depression, and cardiovascular deconditioning, among many others.
Given the clinical outcomes related to the disease and treatment-related adverse effects that CaRE targets, it is imperative that the CaRE services and outcomes are communicated back to the medical team to identify progress and/or concerns. Hence, clinical information sharing via the EMR was an early priority championed by physicians, allied health staff, QEPs, and programmatic administration. CaRE experiences in integrating exercise-programming notation within the EMR underscore the fundamental requirement of collaborative efforts across all groups key to EMR privileges/access. At the Princess Margaret, this group includes human resources (e.g., enter the title of the clinician), data security, and IT, which are all linked by an administrative software system. This is relevant because EMR privileges vary depending on the title of the clinician (e.g., exercise physiologist vs kinesiologist vs research assistant vs physical therapist). IT is the overarching department responsible for the administration of the EMR’s functionality and receives directives from data security related to which staff are eligible for different EMR “desktops” (i.e., the working area/functionality of the EMR platform). EMR desktops permit access to functions relative to the user’s clinical practice and role, such as viewing records, inputting records/notes, and order entry, and are determined in conjunction with their clinical practice leads. Institutional clinical practice leads are thus influential as their role is to oversee the delivery of care within a profession or across similar professions (e.g., rehabilitation sciences), including determining who is most appropriate to deliver and report specific elements of comprehensive clinical care. Accordingly, support from the clinical practice leads was vital in establishing administrative evolutions within data security and IT to include the QEP as appropriately credentialed oncology team member with EMR privileges for access and entry capacity comparable to other allied health professionals. In many ways, this reflected a cultural shift in what constitutes a member of the clinical team that now includes consideration of QEPs with a specific and legitimate role in the management of cancer and treatment-related outcomes. Finally, at the heart of the initiative are contributions from the clinical team to develop a standardized EMR note with appropriate language and content for inclusion in the medical notes. In this respect, QEPs worked closely with other program clinicians to develop relevant notation criteria for the EMR that are both comprehensive and concise.
To facilitate standardized EMR entries by QEPs and to create a platform for implementation science research, EMR templates were designed within eCancerCare—an electronic browser-based platform for point-of-care clinical data entry that is outside the EMR system yet able to transfer data to and from the EMR (6,28). The eCancerCare platform effectively creates a robust clinical research database that permits serial data collection and extraction for longitudinal analyses related to patient-reported and clinical outcomes. eCancerCare has been shown to improve notation completeness and efficiency in bladder and kidney cancer patient care with high clinician satisfaction (6,28). For CaRE, EMR templates were designed by the clinical exercise and rehabilitation team (kinesiologists, physiotherapists, and occupational therapists) to capture point-of-care data entry by clinicians using both discrete fields (e.g., predetermined drop-down menus and selectable boxes for patient information) and/or open text fields. Data entered in the templates can be then algorithmically converted into narrative medical notes and uploaded into the patient’s EMR—a process facilitated by eCancerCare computer programmers. Figure 2 depicts the template with juxtaposed EMR notation. Exercise prescriptions provided by QEPs can be generated by the eCancerCare system and provided to patients to ensure precise records of exercise programs and hardcopy patient documents to refer to while exercising (Fig. 3). In addition to clinician-entered patient information, psychosocial and physical well-being data are entered at each visit by patients via tablets that automatically synchronize with the patients eCancerCare record to provide a global picture of patient health and needs. Collectively, eCancerCare has facilitated comprehensive, efficient, and effective data collection while improving data accessibility for clinicians and researchers that can be linked to other clinical outcomes (e.g., radiology, laboratory medicine, etc.). The development of comprehensive data sets that systematically capture clinical and patient-reported outcomes supports metrics of global impact to align with institutional priorities related to being and remaining an internationally recognized cancer center. The potential value of the database represents an important advancement in exercise–oncology research, as calls for the reporting on knowledge translation in real-world settings emerge from the convincing data in randomized controlled trials.
Experiential Application to the CFIR Constructs
Two coders (LQR and one third party) independently identified CFIR constructs represented in the narratives described above and reconciled any differences in interpretation. Identified CFIR constructs were reviewed by the other two authors as a means of “member checking” (29). Twenty-three CFIR constructs were applicable across one or more centers and are described in Table 1. Ten constructs (evidence strength and quality, cost, patient needs and resources, external policy and incentives, compatibility, available resources, self-efficacy, engaging [e.g., champions, formally appointed implementation leaders], and executing) were shared by all three centers with complexity, peer pressure, networks and communications, relative priority, leadership engagement, and knowledge and beliefs about the intervention shared by two center experiences. The remaining identified constructs were applicable to at least one center (relative advantage, adaptability, structural characteristics, culture, tension for change, other personal attributes, and planning).
Our collective experiences identify the opportunities and challenges that connecting clinical exercise programming with the EMR can present. Irrespective of the state in which EMR may be connected to exercise programs, it is clear from established empirical literature that exercise has clinical value and integration into chronic disease management is overdue. The EMR in this respect can facilitate access to programming, support interprofessional communication and care, and provide an opportunity for the development of a clinical research database for scientific exploration and advancement. Using the CFIR (25) as a guide, we identified constructs within each of the five major CFIR domains that were important across one or more sites (Table 1). Importantly, identifying a champion within the organization with access to resources (financial and otherwise) is critical to implementation. Other important constructs included understanding the networks and communications within an organization, addressing implementation climate regarding relative priority, and adapting to external policies (e.g., exercise professional credentialing in Canada but not the United States), cost, and complexity. The consistency of construct occurrence across most sites is noteworthy and suggests future directions for related implementation science research. Given the relative absence of exercise programming in primary and specialized medical institutions, opportunities remain to further research implementation strategies that target these constructs to advance related initiatives, such as cost, implementation readiness, and engaging champions.
Little is known about how to best intervene on implementation targets when attempting to improve provider referrals and communication regarding exercise resources through the EMR. Although barriers and facilitators related to such communication may overlap with other disciplines (e.g., individual U.S. approach vs a more collective approach toward health care outside the U.S.) (30), a summary of our EMR experiences specifically related to communication with QEPs in tertiary care centers is intended to advise similar activities in other institutions. It is worth noting that studies have shown that exercise counseling provided by the health care provider was not statistically significantly better in practices with an EMR when compared with those with a paper record, suggesting that the EMR link alone may not be sufficient for optimizing implementation (31). Rather, stakeholders engaged in EMR integration of indicators such as physical activity behavior suggest that clinical decision support and feedback with recommendations for the indicators are also essential (32).
Our collective experiences provide practical considerations for clinical exercise programs that would benefit from connecting with the EMR (summarized in Table 2). First, conventional medical paradigms have yet to fully adopt exercise as a therapeutic regimen, and consequently, QEPs are commonly not considered a part of the broader health care team. As such, administrative practices (such as hiring QEPs and defining their EMR training/access) must be addressed to ensure that QEPs delivering clinical exercise programming have the appropriate capacity and privileges. This may require justification of QEP qualifications in specific clinical settings, the role of exercise in evidence-based practice, defining QEP scope relative to other health care professionals, conducting needs assessments of patients to determine preferred skills/qualifications, and metrics (economic and care quality) related to QEP service provision. Targeting the CFIR construct of external policies and incentives could potentially facilitate these efforts, which in turn target implementation science constructs such as implementation readiness.
It is important to note that QEPs delivering exercise-based care may have various educational and training experiences, such as the exercise physiologist, kinesiologist, physical therapist, or registered nurse. Depending on the setting and intended scope of care, any one of these health professionals may interact with a patient for exercise-related care. However, scope of practice must be considered, wherein exercise physiologists and kinesiologists may primarily provide conditioning, functional, and/or performance-related exercise while a nurse or physical therapist may focus on impairment-driven rehabilitative needs to return a patient to functional targets (Fig. 4). This is not to suggest that there cannot be an opportunity for each health care professional to work to the fullest extent of their scope of practice due to role overlap but rather, to highlight their complementary nature where overlap is an asset in addition to the extension of care that each professional’s scope provides. This is relevant in the case of EMR integration because programming in certain settings may not require EMR changes to privileges where they already exist (e.g., nurses and physical therapists). Furthermore, the nature of the health system and third-party payers is that often only certain professional services (e.g., physical therapy and nursing) are funded or reimbursed while others are not (e.g., kinesiologists or exercise physiologists), leading to a potential narrowing of services available to primarily impairment-driven exercises and not general conditioning that is known to provide the aforementioned benefits. These systems and cultures continue to evolve with research and experience and should be considered as contextual factors lending to supports or barriers to exercise programming and EMR integration.
Second, engagement from diverse institutional stakeholders must coalesce to actualize the formal addition of new health care professionals to the health care team. This initiative often requires a champion, and in the medical setting, physician support is paramount. Developing or amplifying a “change-champion” requires consideration of which parties could be involved to contribute support and how to identify such parties (e.g., foundation, patient support groups, institutional clinical groups/teams with common interests), engaging in management discussions related to policy/procedure revision (e.g., pursuing support and feedback from upper administration regarding process, costs, etc.), and collaborative opportunities to define mutual benefit (e.g., clinical and research).
Third, given that the EMR is inherently linked within IT and data security systems, appreciation for the complexity of these systems is essential and strategies for appropriate communication with these team members will enhance productivity and minimize burden. In particular, the following approaches are proposed based on our experiences: (i) develop a clear understanding of the organizational chart elements that encompass the areas of change to the EMR that are sought (e.g., determine which departments/teams have authority for change for different aspects of patient information); (ii) engage in early discussions with the technology team responsible for uploading EMR notes to assess needs, capacity, and institutional style/restrictions; (iii) consider modeling templates based on established EMR notation styles; and (iv) consider opportunities for data extraction to leverage prospects for hypothesis generation and scientific inquiry. Clearly considering the CFIR construct related to networks and communication is key to EMR integration implementation success.
The three centers represented in this paper reflect major cancer centers with capacities that may not be generalizable to a majority of health care centers where adaptation of the EMR to integrate exercise, or clinical exercise programming at all, is not feasible. Each of the three centers assumed significant personnel time and/or other costs to develop EMR notation capacity beyond the development or collaboration with the exercise programs linked to it. Prioritization of resources across diverse and complex demands of the health care systems is justified, and establishing the necessity of exercise in the local EMR is subject to numerous local/institutional contextual factors. Although our experiences are first-hand, qualitative/narrative accounts of the development and advocacy for exercise information in the EMR for oncology patients, longer-term, quantitative data describing the effect of EMR integration on patient referral, physician awareness/support of exercise in clinical care, and health care quality and economic outcomes are needed to fully comprehend the impact of exercise information in the EMR for this population. Moreover, such efforts should seek to identify the implementation science constructs most important for facilitating success when implementing exercise integration into the EMR. Notwithstanding these limitations, we highlight common challenges across our three centers that are likely to be generalizable to other clinical exercise programs within and beyond oncology, namely, a paucity of the QEP workforce with expertise in specific clinical populations to support programming and related EMR initiatives, clinician unfamiliarity with the QEP training and scope of practice, and the novelty of exercise-specific clinical record development that requires an interprofessional approach (including digital teams) to build appropriate EMR access and processes. At present, these remain challenges, rather than barriers, to the advancement of the EIM solutions via EMR integration.
Experiences from three large cancer centers suggest that the introduction of exercise into the medical paradigm may be supported through engagement of the EMR and vice versa. Furthermore, integration of patient-reported and clinical metrics can facilitate hypothesis generation and measurement of the effects of clinically integrated exercise programs for people with cancer. Although implementation of the exercise information by QEPs in the EMR is complex and involves numerous stakeholders, we share potential pathways in achieving this that may serve as precedents for similar endeavors. Further research is needed to determine whether implementation strategies that target identified CFIR constructs can facilitate the implementation of evidence-based exercise programming via EMR.
DSM would like to acknowledge the many and important contributions in advancing exercise into the EMR at the Princess Margaret by Dr. Jennifer Jones, Dr. Eugene Chang, Aleksandra Chafranskaia, Stephanie Phan, Tania Trojetto, Darren Au, Manesha Khazanchi, Kailey Trewartha, Valerie Skeffington, Leanna Graham, Karen Feng, Lynette Chen, Tran Truong, and support from the Princess Margaret Cancer Foundation. LQR would like to acknowledge Sara Mansfield, David Bryan, Alex Yates, Warren Smedley, and Latoya Goncalves. There were no funding sources for the development of this manuscript. The authors declare no conflicts of interest with this manuscript. The results of the present manuscript do not constitute endorsement by the ACSM.
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