Standardizing Physical Activity Assessment in Healthcare: Toward Healthier, More Active Aging

THE PAST The idea of treating physical activity such as a vital sign, captured at every physician visit, displayed prominently in medical charts, and linked to actionable steps, grew out of partnership between the American College of Sports Medicine (ACSM) and the American Medical Association that evolved into the Exercise is Medicine (EIM) initiative, which was launched at ACSM’s annual meeting in May, 2007. Among the first large U.S. health systems to turn this vision into a routine, scalable workflow was Kaiser Permanente Southern California, where Dr. Bob Sallis and colleagues designed and operationalized the Exercise Vital Sign (EVS) in October, 2009 (1). They deliberately kept the EVS to two simple questions focusing on cardiorespiratory activity: On average, how many days per week do you engage in moderate to vigorous physical activity (like a brisk walk)? On those days, how many minutes do you engage in activity? These questions were added to the medical assistant’s workflow and recorded in the electronic health record. Days per week are multiplied by minutes per day to yield self-reported weekly minutes of moderate to vigorous aerobic activity. The EVS helped normalize the routine assessment of aerobic activity for both patients and providers, provided necessary data to inform exercise counseling, enabled referrals to fitness programs and professionals, and created a massive real‑world data set linking activity levels to other biometric data and health conditions such as diabetes, depression, and COVID-19. In parallel, Intermountain Health in Utah advanced the EIM model, led by Drs. Elizabeth Joy and Trever Ball. They developed the physical activity vital sign (PAVS) in 2011, asking three questions that captured days per week, minutes per day, and intensity of aerobic activity (low — such as a casual walk, moderate — such as a brisk walk, vigorous — such as jogging) (2,3). These questions were added into primary care workflows, front-line staff were trained, and, working closely with informatics, clinical decision support was built that nudged clinicians to provide and document advice to start, increase, maintain, or modify current levels of physical activity. Joy and Ball used PAVS documentation and provision of physical activity advice as a quality-improvement and pay-for-performance measure, demonstrating practice improvement in both the short (years 1 and 2) and long (year 3, after cessation of the incentive pay) terms. Internally, Intermountain Health examined the relationship between self-reported PAVS data and healthcare costs from 2014 to 2019 for over 500,000 patients. Unpublished analyses found that patients who were inactive or insufficiently active had significantly higher healthcare utilization and cost of care compared to those who were sufficiently active. Across both health systems, several practical principles crystallized: keep physical activity assessment simple, universal, and fast; collect it at every visit just like other health assessment measures; display it prominently; and, most importantly, link it to actionable physical activity advice, counseling, and referral to physical activity resources. By proving feasibility at scale and demonstrating strong associations between low activity and adverse health and cost outcomes, Sallis, Joy, and their collaborators helped shift professional societies, payers, and electronic health records vendors toward recognizing physical inactivity as a routinely measurable, clinically meaningful risk factor. This collective work showed that a 30-s, two to three-question screening can reframe movement from lifestyle advice to actionable clinical data, seed robust health-services research on dose–response relationships, and provide clinicians with a practical lever to advance prevention and chronic disease management. The importance of asking about physical activity as a vital sign was elevated for healthcare organizations when the following questions were added to the Medicare Health Outcomes Survey (HOS): In the past 12 months, did you talk with a doctor or other health provider about your level of exercise or physical activity? In the past 12 months, did a doctor or other health care provider advise you to start, increase, or maintain your level of exercise or physical activity? The HOS is a key tool used by the Center for Medicare and Medicaid Services to assess the quality of care provided by Medicare Advantage plans. Results from the HOS directly influence an insurance plan’s Star Rating, which affects Medicare enrollment and reimbursement. Today, the PAVS concept is spreading beyond its Kaiser Permanente and Intermountain origins, aided by structured electronic health record database fields, growing attention to social and behavioral determinants of health, and the maturation of referral networks to community exercise resources. THE PRESENT Bringing aerobic activity assessment into electronic health records in the forms of EVS and PAVS represented a seminal advance in connecting lifestyle assessment with routine clinical care. However, the full continuum of patient care includes: standardizing assessment to match prescription with current Physical Activity Guidelines for Americans; referral to community-based organizations, cardiac rehabilitation programs, and medical fitness centers for supervised exercise intervention; and feedback to clinicians (Fig. 1).Figure 1:: Continuum of patient care.The Physical Activity Alliance and the American Heart Association collaborated with a technical consultant and an expert advisory group in the global nonprofit organization Health Level Seven International (HL7). HL7 creates standards to help healthcare systems share and use electronic health information smoothly, which are often integrated into the United States and global regulations. Together, they developed the first-ever HL7 FHIR Physical Activity Implementation Guide (Guide) based on the Physical Activity Guidelines for Americans. The Guide adds a muscle-strengthening question, taken from the National Health and Nutrition Examination Survey (As part of an average week, on how many days do you perform muscle-strengthening activities such as weight or resistance training?), to the existing PAVS questions on aerobic activity. The Guide provides the specification and documentation needed for standardizing adult physical activity assessment (aerobic activity and muscle strengthening), while addressing the need for inclusion of the entire continuum of patient care in electronic health records and clinical workflow, which will allow physical activity data to follow patients on their journey toward healthy living. The HL7 FHIR Physical Activity Implementation Guide is available in the public domain for health system and electronic health record integration. The practice of ongoing testing and refinement of the Guide will ensure it evolves and remains relevant as a normative standard in patient care. Currently, it is challenging for health systems to seamlessly send patient referrals to community-based organizations that do not have Health Insurance Portability and Accountability Act compliant systems. Aided by federal regulation mandating interoperability, intermediaries that connect different parts of the healthcare ecosystem (e.g. Welld Health, Community Care Hubs, Health Information Exchanges) can facilitate links between health system integration, and uptake and interoperability of patient physical activity data, so clinicians can refer patients to community-supervised exercise interventions. To help achieve interoperability, the Physical Activity Alliance worked with the Office of the National Coordinator for Health Information Technology (ONC) to insert physical activity assessment into the US Core Data for Interoperability (USCDI), version 4, with continued inclusion in versions 5 and 6. USCDI represents the minimum core standards required to be in all ONC-certified electronic health records in the United States. Over 95% of acute-care hospitals and nearly 80% of office-based physicians are currently using an ONC-certified system (4). A critical step in this process is having the updated version of USCDI included in the federal interoperability rule to mandate use and uptake by certified electronic health records across the country. The Physical Activity Alliance and partner organizations are advocating for this inclusion with ONC, the Centers for Medicaid and Medicare Services, and the Centers for Disease Control and Prevention. The American College of Lifestyle Medicine (ACLM) has also made important contributions by working with the software vendor Epic to develop an adult lifestyle behavior questionnaire that is now available for all health systems that use their electronic health records system. The ACLM integrated questions from the HL7 Implementation Guide into this assessment tool to assure congruence with interoperability and regulatory standards. These efforts have helped shift the culture of care so that physical activity assessment is not only a data point, but also a conversation starter and clinical imperative in lifestyle behavior assessment and follow-through. Together, ACSM and ACLM are leading organizations in the Physical Activity Alliance, helping achieve national policy and systems changes that make physical activity assessment, program referral, and clinician follow-up a standard of care. THE FUTURE National and international physical activity guidelines for children, adults, and older adults have been updated and expanded since the inception of the EVS and PAVS. The most significant changes from the previous U.S. recommendations (2008) to the current guidelines (2018) occurred within the fastest-growing demographic in the United States, people 65 and older (5). Current recommendations for older adults include the following: 150 min·wk⁻¹ of moderate or 75 min·wk⁻¹ of vigorous intensity aerobic physical activity muscle-strengthening activities of moderate or greater intensity on two or more days per week weekly balance activities (duration and intensity unprescribed) One of the changes in the 2018 guidelines is the recommendation that all older adults, regardless of their risk of falling, should engage in weekly multicomponent activities that include balance training. The critical need to participate in multicomponent activities is related to: slowing down or reversing age-related changes; preventing falls, frailty, and functional decline; promoting independent living and participation in activities that are important to older adults (i.e., attending family events, being able to go into the community). These updated recommendations are particularly important to this group because the benefits of regular physical activity and the consequences of not meeting the physical activity guidelines are greater. Not meeting physical activity guidelines is one of the strongest predictors of falls and frailty, and compared to younger individuals, older adults are 33% more likely to experience a fracture when falling (60% more likely if they are 85+) (6). Encouragingly, a recent systematic review and meta-analysis found a 23% falls risk reduction in people assigned to exercise vs. control in randomized controlled trials. “We found exercise that mainly involved balance and functional training reduced falls compared with an inactive control group. Programmes involving multiple types of exercise (most commonly balance and functional exercises plus resistance exercises) probably reduced falls, and Tai Chi may also reduce falls. We did not find enough evidence to determine the effects of exercise programmes classified as being mainly resistance exercises, dance, or walking programmes. We found no evidence to determine the effects of programmes that were mainly flexibility or endurance exercise” (7). The initial EVS and PAVS focused solely on aerobic activity (1). Due to the increased focus on multicomponent activities that improve aerobic capacity, muscle strength, and balance in current physical activity guidelines for older adults, it is essential to revisit physical activity assessment tools being used in clinical settings, which have been created for the adult population. In 2018, EIM recommended that a previously validated question on muscle-strengthening (How many days a week do you perform muscle-strengthening exercises, such as bodyweight exercises or resistance training?) should be part of the PAVS utilized in clinical settings. This muscle-strengthening item was also included in the clinical suggestions provided by the 2018 American Heart Association’s Routine Assessment and Promotion of Physical Activity in Healthcare Settings (8). A similar question in the valid and reliable Physical Activity and Sedentary Behavior Questionnaire is “In a typical week, how many times do you do muscle-strengthening activities (such as resistance training or very heavy gardening)?” (9) In 2024, Stoutenberg et al. (10) recommended that the following balance item also be added to the PAVS: How many days per week do you perform activities that challenge your balance, like standing with feet together or walking on trails? This item originated from the Wingood et al. (11) publication of a physical activity care pathway that provides guidance on assessing and addressing physical activity within geriatric care. Conclusion The assessment of physical activity in clinical settings has evolved over the past 2 decades and, aided by several policy initiatives, should become the standard practice in U.S. health systems. One area that needs further attention is evidence-based physical activity counseling for older adults, which must include recommendations for strength and balance training. The next step is to refine physical activity assessment questions specific to older adults for fall-risk prevention and frailty mitigation, to facilitate optimal referral and follow-through. In order to create evidence-based balance questions, optimal balance training intensity and duration need to be defined through randomized controlled trials. Refinement also includes evaluating patients’ cognitive understanding of the entire tool set of multicomponent physical activity questions being considered, exploring the practical usability of these tools among diverse populations, and performing psychometric testing of individual questions and question sets. Electronic health record systems should evolve to capture the entire physical activity (PA) continuum-of-care, including automated PA program referrals and PA program provider feedback, which will fully integrate PA professionals into health care teams. Finally, as a recent review of physical activity assessment instruments makes clear (10), there is a diverse range of questions being used across a swath of unique instruments. This heterogeneity is unfavorable to the field. We call on leading experts to begin a dialogue about creating a single, standard set of questions, based on currently approved physical activity guidelines, specific to children, adults, and older adults, that should be adopted by all. PRACTICAL APPLICATIONS This Commentary should guide thinking about how the field of Exercise as Medicine constructs, delivers, and follows up on physical activity assessment questions in electronic health records. A goal should be to complete the entire continuum-of-care within healthcare systems: PA assessment, PA program referral, and clinician feedback (Table 1). TABLE 1 - Policy and implementation road map. Implementation Time Frame Short-term: Advocate for insurance reimbursement for clinician PA assessment and referral Mid-term: Create nationally standardized sets of evidence-based PA questions that vary by population age (children, adults, older adults) and incorporate into EHR systems Long-term: Close the continuum-of-care circle by including PA program provider data into EHRs for improved clinician PA counseling The results of the present study do not constitute endorsement by the American College of Sports Medicine. The authors declare no conflicts of interest.