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Exercise Is Medicine as a Vital Sign

Challenges and Opportunities

Bowen, Pamela G.1; Mankowski, Robert T.2; Harper, Sara A.3; Buford, Thomas W.3

Translational Journal of the American College of Sports Medicine: January 1, 2019 - Volume 4 - Issue 1 - p 1–7
doi: 10.1249/TJX.0000000000000076
Review Article

ABSTRACT Exercise is widely recognized as a critical component of a healthy lifestyle by multiple scientific and regulatory bodies. Yet only 35% of adults in the United States even report engaging in regular physical activity. In response to this challenge, the Exercise Is Medicine (EIM) initiative encourages clinicians in all settings to regularly assess and counsel patients on physical activity in an attempt to reduce levels of inactivity. The purpose of this article is to highlight key challenges to the implementation of the EIM initiative to promote physical activity and to identify potential opportunities to overcome these challenges. EIM is a global health initiative that endorses “exercise” to be a “vital sign” in all clinical settings, specifically to assess and compare the patient’s physical activity level to national guidelines for physical activity and then promote discussions or referrals based on results. Since its 2007 launch, advocates of the EIM initiative have increased global awareness to promote the EIM mission of integrating and implementing physical activity into health care systems, local communities, and individuals’ daily lives. Physical activity is fundamental to the overall health of all people across all geographic locations and throughout the life span. Promoting physical activity as a healthy lifestyle change has specific challenges but necessary to decrease health disparities related to inactivity.

1School of Nursing, University of Alabama at Birmingham, Birmingham, AL;

2Department of Aging and Geriatric Research, University of Florida, Gainesville, FL; and

3School of Medicine, University of Alabama at Birmingham, Birmingham, AL

Address for correspondence: Pamela G. Bowen, Ph.D., NB 540, 1720 2nd Ave., South Birmingham, AL 35294 (E-mail: pbowen@uab.edu).

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INTRODUCTION

Exercise Is Medicine: Overview

Exercise Is Medicine (EIM) is a global health initiative that began in the United States in 2007 and resulted from the collaboration between the American Medical Association and the American College of Sports Medicine. The EIM initiative has three primary aims: 1) to encourage clinicians to evaluate their patient’s physical activity (PA) level at each clinic encounter, 2) to compare each patient’s current PA level with the national PA guidelines, and 3) to provide PA counseling and/or referrals to each patient who does not meet the national guidelines (1). In line with these objectives, exercise/PA participation has been proposed as a potential clinical “vital sign” (2) because of the broad reaching health benefits as well as the recognized benefits of clinical prescriptions on PA participation (3,4). Using exercise as a vital sign (EVS) would be a promising tool to assess PA levels of all patients during each clinic visit in an effort to reduce or manage chronic conditions that are exacerbated by inactivity and sedentary behavior (2). As such, PA evaluation proposes to be an important component of standard medical care (5).

A select few studies have demonstrated the promise of integrating EIM within “real-world” settings. The most notable of these is the experience of the Kaiser Permanente health care systems (Southern and Northern California) adopting an innovative program to evaluate EVS (6,7). Briefly, clinicians across the health care system assessed and evaluated patients’ current activity level by asking two questions: 1) “On average, how many days per week do you participate in moderate to vigorous PA (e.g., a brisk walk)?” and 2) “On average, how many minutes per day do you perform PA at this level?” and by programming the electronic medical record (EMR) to multiply the data points for these two questions to provide a total number of minutes per week a patient engages in PA, which will also decrease human error.

Tracking data from nearly 20 hospitals and millions of patients, these studies revealed that the EVS assessment had strong face and discriminant validity. (7) The EVS program resulted in more clinicians documenting their patient’s exercise levels and making exercise referrals. Although physical activity may improve hemoglobin A1c levels and assist in weight loss, it is important to note that patients with obesity or diabetes, who received care at EVS sites, may have benefited from additional dietary counseling to achieve more weight loss and greater declines in hemoglobin A1c levels when compared with medical centers not using the EVS program. (6)

More recently, Heath et al. (8) assessed and evaluated the acceptability of clinic-based EIM protocols with clinicians and fitness professionals. During the 6-month acceptability phase of the study, clinicians and fitness professionals indicated that they would incorporate these EIM protocols into their practice routine, endorse EIM to other colleagues, and recommend that the EIM protocols and community referrals be integrated into EMR. The intervention phase of the study was 16 wk. The participants who received the EIM protocol plus the community programming (individualized PA plan, Y-membership, and access to a personal trainer) increased their total PA compared with the EIM only group (only provided PA information). Participants in the EIM plus group increased their total PA roughly 250 min·wk−1 compared with their EIM only counterparts that showed a decrease of approximately 38.6 min·wk−1. Elsewhere, other reports have described the relative utility of (9,10) and indicated the potential utility of EVS questionnaires in predicting health outcomes (11,12). These results suggest that EIM plus is a promising approach to significantly increase PA among inactive adults (8).

One of the Healthy People 2020 top priorities for improving health is PA across the life span (13). Unfortunately, traditional challenges to exercise commonly cited by patients and others populations (i.e., specific to age, race, or region) include safety issues (loose animals, crime, and high-velocity traffic), health problems, not having the proper clothes or enough money, being tired, no partner, insufficient time, or competing priorities such as family or work responsibilities, neighborhood walkability, and inadequate transportation or facilities to engage in PA (14–19). Comparably, limited rural and primary clinicians willing to provide PA counseling, lack of PA education or engagement for clinicians, and inadequate environmental infrastructures that support an active lifestyle are just a few barriers that clinicians and policy makers should consider to successfully integrate EIM into primary care (19–21). Thus, these areas represent key opportunities for improvement and engagement to reduce health-associated risks of inactivity. Fortunately, the EIM initiative may provide a strong foundation for beginning to address these challenges.

Notably, during the drafting of this manuscript, the American Heart Association released an important scientific statement regarding the concept of physical activity assessment and promotion in the health care setting (22). Readers are encouraged to read this important work as it has influenced several of the points made herein and has important relevance to topics discussed throughout this manuscript.

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Challenges to Implementation of EIM

Clinicians

The EIM® (1,23–25) and the Healthy People 2020 (13) initiatives both encourage clinicians to regularly assess and counsel patients on PA in attempt to reduce levels of inactivity as PA is rarely assessed or discussed at clinical visits (19,26,27). Therefore, framing PA to clinicians to be valued at the same level as traditional vital signs or a medication that needs to be taken daily is a fundamental challenge to implementing EIM in all health care settings (2,28,29).

Clinicians cite competing time demands as a major barrier relevant to the EIM initiative, which results in the relative scarcity of providing PA counseling to patients (30–33). In fact, many clinicians are less likely to provide health habit counseling such as PA discussions with their patients, which often results in decreased of patient satisfaction and patient–provider relationship, and this may impede educational efforts (34). Busy clinicians often run late with appointments because many patients have multiple health concerns, which usually results in no time for PA discussions (33,35). In addition, as the number of risk factors or comorbidities decrease, patients are less likely to receive PA counseling (36). Furthermore, knowledge deficits to counseling and tailoring recommendations, uncertainty of safety for patients with complex comorbidities, inadequate tools and resources, and a lack of provider incentives or motivation to discuss PA are additional perceived barriers (33,35). Yet despite these barriers, clinicians are more likely to counsel patients to exercise who have or are at risk for chronic conditions such as diabetes, which suggest that exercise is recognized as an important strategy for disease management (36).

Many clinicians also work in isolation with decreased personnel and limited finances and community resources to support exercise facilities or parks to facilitate active living, which are barriers to implementing PA discussions with patients (35). Moreover, some clinicians perceived PA counseling to be outside their scope of practice and their patient’s cultural background, gender, age, and motivation or lack of influenced provider’s perceived barriers to PA assessment and counseling. Studies have shown that clinicians play an important role in and authority for addressing the increasing problem of physical inactivity and its impact on chronic disease development and management (37,38). Although clinicians are indeed trusted resources for disease prevention and health promotion information, only 32%–34% of patients receive even minimal lifestyle counseling – such as PA advice – during their annual health care visits (27,32,39).

Other major challenges for clinicians in integrating PA assessments include the following: no or inadequate reimbursement (40), no codes (diagnostic or consultation, prevention, and treatment [CPT]) that are recognized by government and commercial payers (22), and lack of competencies, training, self-efficacy, or necessary skills required to counsel patients effectively about PA (32,41). This is perhaps not surprising given that the majority of medical schools do not offer any PA education-related courses for medical students, or when offered, they are rarely required (20,38,41). Insufficient personal PA practices of providers may also present a challenge. Research suggests that clinicians who are physically active themselves are more likely to counsel patients about PA and may serve as a more convincing role model to their patients (38,42).

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Health Care System

Because clinicians are not incentivized to perform PA counseling and education, health care systems are charged to make prevention-oriented care, PA counseling, and educational activities a priority for the patients it serves. In addition, health care systems have other multiple-level barriers that may prevent PA discussions such as no standardized PA coding schemes, applicable reimbursement strategies, or models that are sustainable; health care effectiveness data and information sets/ summary scores of health-related quality of life for patients; acceptable linkages to certified PA programs, facilities, or personnel; or patients have higher out-of-pocket cost (1,22,40). Although national initiatives to reduce physical inactivity exist, the major challenge for health care systems is how to overcome these barriers in an overall fragmented health care society and to build an infrastructure that supports the integration of PA counseling (13,19,22,43).

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Community Partners

Although the EIM initiative emphasizes the use of qualified exercise professionals as an integral component, clinicians are many times unaware of or uncomfortable in referring their patients for exercise guidance by exercise professionals outside their clinical network (1). The same may be true for community centers or facilities that do not have a partnership with the health care system. Hence, the integration of clinical and community services to encourage PA may be logistically challenging (44). However, it is imperative that stakeholders of the community and health care organizations work together to create and improve the infrastructure between health care organizations and communities to support safe places and programs to increase PA engagement (21). These actual or perceived barriers among clinicians and health care systems present major challenges – as well as opportunities – to improve both patient PA engagement and overall health. Thus, the EIM initiative may provide a strong foundation and potential opportunities for beginning to address these challenges.

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Opportunities for EIM as a Vital Sign

Ultimately, for the EIM initiative to achieve its goals, efforts are needed at a variety of levels. Although likely not comprehensive, we envision important contributors to be not only individuals such as scientists and clinicians but also larger entities including entire health care systems and community organizations. It seems likely that only such a comprehensive effort will ultimately counterbalance making exercise a personal priority in an age where the majority of the population may need to make special efforts to engage in PA. Here we outline some of the possible opportunities to address physical inactivity, with emphasis on advancing PA engagement.

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Clinicians

Substantial evidence supports that clinicians may be fundamental change agents for their patients to incorporate PA into a routine (4,38,41). Typically credible and respected sources of health information and trusted by patients, clinicians are uniquely positioned to assess and review every patient’s PA level at each visit. Unfortunately, rates of PA counseling from clinicians are quite low (27,32,39), which is one of the top priorities listed for change in the Healthy People 2020 initiative (13).

One significant approach to implementing the EIM initiative is to persuade clinicians to make a pledge to include PA counseling and referrals during their patient encounters. However, even if clinicians aim to incorporate PA assessments and counseling at every visit, provider time constraints are a major barrier (30); thus, efficient and valuable strategies to assess PA levels are needed (31). As evidenced by the Kaiser Permanente experience, integrating PA assessments as a vital sign into the EMR is a good method to prompt clinicians to make PA assessment and counseling a priority. Indeed, evidence indicates that this approach can trigger clinical care processes, which foster the inclusion of health promotion activities to improve patient health outcomes in an efficient manner (6,8).

Another key strategy to execute the EIM initiative is to encourage all clinicians to assess PA levels and to provide individualized PA counseling and prescriptions at every visit. Prefacing “exercise or PA” as a “medicine or a vital sign” may help clinicians to rethink the value of PA as essential for good health instead of as a “health enhancing” activity (28). Here, we propose three important topics that could be incorporated into clinical training programs: 1) the rationale for considering PA as a vital sign, 2) techniques for persuasively encouraging patients to engage in regular PA (28), and 3) the importance of clinicians themselves engaging in regular PA. In addition to modeling healthy behavior for patients, participation in PA by clinicians encourages professional balance and good quality of life (32).

A third method is to reimburse or incentivize clinicians to discuss PA with their patients. Unfortunately, clinicians may be unaware of the existing reimbursement procedures. Increased awareness of appropriate billing codes for PA-related care, such as “energy balance [counseling related to PA and diet]” or “bill for time”, as ways to receive compensation for PA medical services are needed (22,40,45). For example, the Affordable Care Act has several provisions designed to prevent or improve chronic health conditions—one such provision is the Medicare Coverage of Annual Wellness Visit. This no-cost visit encompasses the health risk assessments, which allows patients to receive PA behavioral risk evaluations and an individualized wellness prevention plan (22,46). Perhaps increased awareness of monitoring patients and billing for “energy balance [body mass index assessment, diet and PA counselling and referral] care” may be another opportunity to incentivize clinicians to discuss PA with patients (45). Klabunde et al. (45) found that clinician practices that bill for energy balance care were more likely to provide comprehensively this care to patients. Unfortunately, less than 45% of clinicians bill for this care. “Bill for Time” with evaluation and management codes is also a good but underused strategy (22). For example, an established patient with the 99214 code allows the clinician to bill for an in-person counseling visit that is greater than 50% of the total 25-min visit, using the appropriate documentation (47).

In the fourth method, clinicians have the primary role to promote health and prevent disease using a holistic approach to healthy lifestyle changes for patients (48). Because of limited time and resources, expanding the role of other health care members such as medical assistants, nurses, and physical therapists to implement PA promotion may be the catalyst needed to breed success (22,48). For example, training for medical assistants could be expanded to include PAVS during their vital signs assessments, which sequentially may reduce clinician burden and provide more opportunities for PA counseling or discussions (43,49). In addition, referring to health coaches may also help patients to sustain PA engagement in between primary care visits (48). In particular, health coaches can approach lifestyle changes in behavior with patients from a psychology (health, positive, and growth paradigms) perspective, which would complement the care and education the patient receives in clinic.

Given the challenges facing patients, it will be especially important for clinicians to have proper training and to value the importance of exercise and PA. Furthermore, many clinics have limited time and complex patients with multiple comorbidities (30,50); approaches that expedite the PA assessment/counseling within a brief clinic appointment (see Table 1 for one possible approach) are essential. Similar to the proposed approach in Table 1, the EIM initiative developed a one-page, downloadable “Clinicians Action Guide”, which also provides busy clinicians with a time efficient tool to empower all patients regardless of PA level to make healthy lifestyle changes (1). However, it is important to consider one recommendation that emerged from the validation of the Kaiser Permanente EVS, which was to add the following time frame to the question: “In the last 30 days, on average, how many days per week did you … or in a typical week…”? By prefacing the questions with a time frame, the data will be comparable with evidence-based population PA surveys and assist in obtaining cross-sectional PA data that patients consider their “usual” PA pattern (7).

TABLE 1

TABLE 1

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Health Care Systems

To create a health care standard of making PA a vital sign, system-level changes are crucial for success (1). Health care organizations must recognize and accept that regular PA is the key to improving population health and potentially reducing the nation’s overall health care costs (19). Because of limited resources, health care systems may need to develop creative ways to sustain EIM as a vital sign. One such creative method to improve feasibility of the EIM initiative is to focus on PA assessments tools and wearable PA monitors that are most compatible with the health care system and the patients the health care system serves. Lobelo et al. (22) identified 14 PA assessment tools that were used in health care settings. Because clinicians have many competing demands, strategies to integrate PA assessments as part of the traditional vital signs assessment increases the probability that these objective measures will be obtained during each clinic encounter (22). Moreover, many PA tools developed for health care settings take less than 5 min to complete, range from 1 to 12 items, target adults and older adults, and have a clinical feasibility that ranges from 2.8 to 1.8 out of a maximum score of 3, which provides for selection options based on preference.

Another approach to increase EIM feasibility is by imbedding exercise vital signs questions into the EMR (22) along with an electronic reminder. The EMR may be designed in several ways to meet the needs of the health care system. First, the EMR may either provide a “pop-up” reminder for the clinician or prevent the progression of the note by the clinician until completion of the PA vital sign. Next, a clinical decision algorithm could be incorporated into the system that would suggest tailored PA recommendations based on the patient’s PA vital signs and health conditions. This could be accomplished by establishing a partnership with the health system information technology group or department to make this process as automated as possible. In particular, the EMR should include smart phrases or smart sets for the clinician to use that automatically takes them through the steps accurately assessing and documenting each patient’s physical activity levels.

On the basis of the populations the clinic serves, the EMR can be customized to prompt the clinicians about available community resources/ facilities, referrals to exercise professionals, including the American College of Sports Medicine’s ProFinder online database, and other services available to assist patients with meeting the national guidelines for PA (1). The EMR could also be designed to provide tailored educational materials, print PA prescriptions, and make PA referrals based on the patient’s zip code, income, or need. Importantly, purchasing any tool that can assess a patient’s cardiometabolic risks, overall health, and current PA levels as well as reduce the clinician’s workload is critical (22). Furthermore, the successful integration and adoption of the EIM initiative into any health care system will depend on input not only from the administrators but also from stakeholders such as clinicians, nurses, and information technology specialists.

With the enactment of the 2009 American Recovery and Reinvestment Act, hospitals and eligible provider offices were incentivized to convert over to EMR (51). This conversion would allow health care systems and clinical practices to demonstrate and document meaningful use, which encompasses such behaviors as improvements in quality, safety, care coordination, population health, reductions in health disparities, and maintenance and privacy of patient health information. Thus, implementing PA as a vital within the EMR of health care clinic sites should be feasible given buy-in from health system leaders (51).

One strategy to reduce health care system decision-makers’ perceptions that PA counseling and advice are an increased burden, methods to obtain and use data from wearable activity devices or smartphone apps could be incorporated into the health care system (19,22,52). Smart technology is an excellent tool to assess whether patients are meeting the national recommendations for PA, which will allow clinicians the ability to individualize PA advice (19,53,54). However, developing methods for health care systems to synchronize the collected PA information from patients with the clinician’s medical database would be beneficial. For example, synchronizing information gathered by commercially available accelerometers (e.g., Fitbit and Garmin) with a clinical database may provide very valuable information, which allows the clinician to assess the patient’s current PA level efficiently, further counsel on reducing inactivity levels if applicable, and monitor progress toward achieving set fitness goals. Still, significant efforts are needed to make this “smart technology” approach a reality—particularly within smaller hospitals or health care systems that service rural areas.

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Community Partners

Although the EIM initiative recognizes that PA as a vital sign is essential to good health and overall well being, community level strategies and partnerships are needed for successful implementation (1). Moreover, it is essential for clinicians, health care systems, and organizations to work together with urban and rural communities to identify safe places to exercise, provide an updated list of PA programs locally offered, and develop a network of certified fitness providers or exercise professionals. For successful implementation of PA as an essential component of routine health care, clinicians, exercise professionals, and community resources are three primary stakeholders that must be involved to manage patients who do not meet the national PA recommendations (1). Specifically of the three, clinicians may be the most critical because patients generally trust and value their advice regarding overall health care, which encompasses PA counseling (19) and referrals to physical fitness professionals and community resources (1).

The integration of clinical and community services to encourage PA can be logistically challenging (44). However, it is imperative that stakeholders of the community and health care organizations work together to create and improve community infrastructures to support safe places and programs to increase PA engagement (21). One potential way to reduce clinician burden and to increase awareness of available community resources is to develop a list of available community partners or a PA referral network that encompasses qualified programs, places, and professionals that can assist patients with meeting their PA goals (1). Ideal places for patients to engage in PA that are convenient and safe may include medical fitness centers, commercial health clubs, school system facilities, municipal community centers, park and recreational facilities, hospital wellness centers, and YMCA facilities (1). Most often, people who live in more remote areas must travel long distances to gain access to these community services and programs, which may be both time-consuming and expensive (55). Therefore, transportation resources are also an integral component of the referral network to consider.

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Scientists

In recent years, research has revealed significant information regarding the substantial health benefits of physical exercise. Yet despite these scientific advances, the translation of successful exercise interventions from structured clinical trials into clinical practice and community programs has remained largely elusive. The EIM initiative suggests both clinicians and scientists to play an active and critical role in promoting regular PA to prevent disease and to promote good health in patients and the community (56). One of the most effective ways for researchers to make a public health impact is by conducting and then disseminating results from rigorous randomized control trials of exercise and PA-based interventions.

Still, challenges exist regarding the successful dissemination of PA intervention results (57). First, there are rarely consistent outcome measures among studies to compare findings. Second, the appropriate mechanism for dissemination of results may vary based on preference (i.e., smartphone or Internet use may vary based on age). Finally, it is difficult to document consistently all details regarding the requirements for the implementation, adoption, and maintenance phases of the study (57). However, developing a data network infrastructure that incorporates and initiates partnerships among health care systems nationally may hold promise. Having common data network models and infrastructures that allow for storage; continuity; enhancing, analyzing, and dissemination of comparative effectiveness; patient-centered outcomes; and PA research available to health care systems, clinicians, and community partners may ultimately improve health outcomes through translational research (58). In addition, it is critical that scientists think in terms of creating and testing interventions that can be feasibly disseminated either within clinical arenas or within the community. This approach requires significant forethought and dialogue with the clinicians and community leaders who would be responsible for such implementation. Moreover, there is an increased need for involving potential patients/community members in the planning stages of the research (59).

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CONCLUSION

One of the recommendations that came out of the validation of the Kaiser Permanente EVS was adding a time period to the question, “In the last 30 days, on average, how many days per week did you…”, which is critical for two reasons. One is that it is comparable with the population-based surveys of PA that are based on decades of evidence that people need time frames to measure their actual PA instead of a general assessment of their PA habits. Second, it may be difficult to use the EVS for changes over time if the assessments are not framed to index what is happening at a particular point in time instead of a general statement of PA, which does not change for most people and thus is not sensitive to intervention effects.

Participating in regular PA is an essential and vital lifestyle behavior that Americans across geographic regions and throughout the life span should engage to gain overall long-term health benefits (60). Numerous studies have demonstrated that – regardless of sex, race, and age – individuals who are habitually physically active live longer, are healthier, and have better-quality lives (61,62). Because promoting an active lifestyle is considered a priority, it is essential that influential stakeholders, such as policymakers, encourage the development and implementation of strategies that will improve health, such as building environmental infrastructures (widening the shoulders of rural roads or developing playgrounds or parks) in an effort to make PA more enticing (19). In addition, clinicians can motivate people to meet the recommended federal guidelines for PA by initiating EIM program during every patient encounter. By treating PA as a vital sign, the importance of engaging in regular PA will remain in the forefront for all clinicians and their patients (1).

This manuscript was supported by the Department of Health and Human Services; the National Institute on Minority Health and Health Disparities (grant no. 3U54MD008602-03S1 FAIN: U54MD008602); the Gulf States Collaborative Center for Health Policy Research (grant no. U54MD008602); the National Institutes of Health (grant nos. R21AG049974, P2CHD086851, and R01AG056769); and University of Florida Claude D. Pepper Older Americans Independence Center (OAIC) (grant no. P30AG028740).

The above-listed grants supported protected time for the authors to complete the work. The authors do not have any conflicts of interest to disclose.

The views of this manuscript do not constitute any official endorsement of the American College of Sports Medicine.

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