Submitted By: Laurie P. Whitsel
/ American Heart Association/Physical Activity Alliance
Data Element Information
Rationale for Separate Consideration
Physical activity level, including aerobic activity and muscle strengthening, congruent with the Physical Activity Guidelines for Americans, are the foundation of the measures we are proposing to use. The measures we are proposing consists of two parts: the “Exercise Vital Sign” for aerobic activity and an assessment for muscle strengthening. However, these are not vital signs in the traditional sense and would not make sense to represent there, as they are an assessment of lifestyle, not of specific physiological measurements.
A low level of physical activity would often be a “Health Concern” and some systems may in fact track it this way. However, this proposed measure is much like Tobacco Use/Smoking in that it reflects “current state” of the patient, whether that is a cause for concern for intervention or not. As such, it makes sense to track physical activity level distinctly as a health concern and to create a Health Concern related to physical activity if necessary.
Use Case Description(s)
Use Case Description
Providers typically capture and share information about physical activity in the same manner as information about other lifestyle factors such as smoking and substance use. Clinicians assess a patient’s level of physical activity against the Physical Activity Guidelines for Americans based on age and may drive interventions such as counselling or referral.
Physical activity level can also be trended over time to help assess whether a patient’s levels are improving or declining.
Clinical systems share these measures as part of the referral process and as part of patient record transfers.
The Physical Activity Guidelines for Americans call for the capture of two measures – minutes/week of moderate to vigorous aerobic physical activity and days per week of muscle-strengthening activity. This proposal follows the literature-validated approach of splitting the first measure into two components of days/week and minutes/day, which patients have an easier time estimating and therefore produces a value more reflective of their actual aerobic activity level.
Device data, such as step counts and heart rate information, can sometimes support Exercise Vital Sign measures where patients have access to devices. However, further research and validation are necessary to integrate those kinds of measurements into assessment, prescription, referral and patient follow-through.
The page at the link below provides more detailed support for the importance of capturing and sharing physical activity information, including literature references.
Estimate the breadth of applicability of the use case(s) for this data element
Per the US Physical Activity Guidelines, practitioners should capture and assess this element for all patients beginning at the age of 3 years. This equates to hundreds of millions of patients and about a million physicians, nurses, and other clinicians.
Public health, payers, clinicians, and others have a significant interest in assessing the level of aerobic and muscle-strengthening physical activity across patient populations, given the correlation between physical activity levels and patient health outcomes. Systems may report physical activity levels as patient health measures or as part of public health surveillance on an identified or de-identified basis. This type of reporting is not currently common standard of practice but is growing to inform the relationship between physical activity and patient outcomes and improve physical activity public health surveillance across the US population.
When clinicians have identified a deficiency in a patient’s physical activity level, the clinician may refer the patient to the appropriate professional for interventions to help improve or sustain their physical activity levels. In such cases, clinical systems may communicate the physical activity measures to payers to support reimbursement for services and to service providers to provide an initial baseline for evaluation. Patients may also regularly capture the measures and share them with ordering providers, service providers, and-or payers to monitor progress.
Estimate the breadth of applicability of the use case(s) for this data element
Approximately 75% of the U.S. population is inactive or otherwise do not meet the Physical Activity Guidelines. This includes about 75% of school-age children (83% of adolescents) who do not meet the recommended levels of physical activity. For adults 65 years and older, more than 86% do not meet the Guidelines. While not all would qualify for intervention, it is important to move toward standardizing exchange of this data element across health systems, payers, service providers and public health surveillance to optimize patient health outcomes.
Maturity of Use and Technical Specifications for Data Element
Applicable Standard(s)
The following LOINC codes correspond to components of the proposed measures:
89555-7 – Physical Activity – Days/Week
68516-4 – Physical Activity – Minutes/Day
82291-6 – Physical Activity – Muscle-Strengthening
For the overall minutes/week measure, there is a standard LOINC code 89574-8 – Exercise Vital Sign that groups the Days/Week and Minutes/Day component, however it does not actually support capturing the calculated Minutes/Week component, even though the submitter of the code (Kaiser Permanente) makes regular use of the calculated value. HL7 will work with Kaiser and Regenstrief to either allow the existing ‘panel’ code to capture the calculated days/week measure or add an additional component that supports the calculation, making it easier to query for patients outside guideline without requiring client-side calculation.
The Physical Activity FHIR implementation guide is going to ballot in the 2023-May cycle and HL7 should published it in Fall, 2023. HL7 hosts the draft continuous integration build version here: https://build.fhir.org/ig/HL7/physical-activity.
Current Use
In limited use in production environments
Supporting Artifacts
The two components of the Exercise Vital Sign are part of the 2015 Certification Companion Guide on Social, psychological, and behavioral data (Paragraph (a)(15)(v)). A sizable portion of the U.S. EHR population has voluntarily certified to these criteria.
Of the few healthcare systems that collect physical activity data, Kaiser Permanente is the largest system. Kaiser Permanente insures over 12 million people. Utilizing the Exercise Vital Sign, it is asked at every outpatient encounter with a healthcare provider. During 2020, there were over 31 million scheduled visits, which suggests this measure is quite extensively used each year.
5 or more. This data element has been tested at scale between multiple different production environments to support the majority of anticipated stakeholders.
Supporting Artifacts
There are about 150 EHR systems that have met the certification criteria for §170.315(a)(15) Social, Psychological, and Behavioral Data. This represents about 30% of the commercially available EHR systems voluntarily including this into their systems, suggesting a significant interest in the wider adoption of this standard. These criteria include two questions regarding physical activity like what we are proposing.
If we consider the use of the Exercise Vital Sign we propose, in the Kaiser Permanente system, the Exercise Vital Sign is asked at every care visit in their network of over 700 medical offices and other healthcare facilities. That represents extensive use of exchanging data between the various healthcare facilities, as well as to patients.
Other healthcare systems, such as Intermountain Health, use the Physical Activity Vital Sign (a similar questionnaire as the Exercise Vital Sign) within their EHR at their 225 medical offices. Furthermore, Prisma Health in Greenville, SC has twenty medical offices that participate in a physical activity assessment and referral program, Exercise is Medicine – Greenville. Staff screen participants for physical activity using the Physical Activity Vital Sign recorded into the EHR system. Their systems exchange the information with local YMCA organizations and patients. These are just examples of health systems where organization are integrating the data element into their standard of care.
Restrictions on Standardization (e.g. proprietary code)
The base components of the measure are all freely available LOINC codes and we do not anticipate an issue in either updating an existing LOINC code or introducing a new one to capture the total minutes/week measure.
There are other measures that are used in parts of healthcare to assess physical activity, including the Rapid Assessment of Physical Activity and Physical Activity Vital Sign which were reviewed in a 2018 AHA Scientific Statement . However, based on a literature scan as well as an HL7-convened expert group, it seems that the Exercise Vital Sign is the most appropriate and widely used measure and is an appropriate foundation to drive increased standardization.
Restrictions on Use (e.g. licensing, user fees)
None
Privacy and Security Concerns
This information could fall under the banner of personally identifiable healthcare information under HIPAA if captured in a healthcare setting, though it has a lower sensitivity level than most healthcare data. If captured and shared outside of a healthcare setting (e.g., on a personal device or shared between a patient and a personal trainer), there would be no HIPAA restrictions.
Estimate of Overall Burden
Nearly all patients can estimate these values and the effort should require minimal time (~30 seconds) to report either by questionnaire or in conversation with a practitioner. Clinicians would typically gather this information as part of the same workflow as other lifestyle measures such as smoking and substance use. Where a patient engages in ongoing monitoring, it would typically only require reporting one measurement per month.
At present, devices are providing supporting data such as heart rates, step counts, move minutes, exercise modality, etc. However, there is opportunity for the device data reporting to be more precisely congruent with Physical Activity Guidelines recommendations.
EHR implementation would build on existing support for reading and writing Observation-based data and would fit into existing standards-based capture of lifestyle information. For those systems that already adhere to the optional certification criteria, it would only mean introducing the one new strength-based measure, which should fit into the same workflow, user-interface, and data exchange code.
Other Implementation Challenges
Because the patients report and estimate the values, accuracy can vary. However, high accuracy is not necessary. Precision within 20-30% is sufficient for determining whether intervention is necessary or appropriate. Eventually, device data may be an important supplement or affirmation of self-reported data.
This information is rarely culturally sensitive, though some patients may feel reluctant to share their information.
ONC Evaluation Details Each submitted Data Element has been evaluated based on the following criteria. The overall Level classification is a composite of the maturity based on these individual criteria. This information can be used to identify areas that require additional work to raise the overall classification level and consideration for inclusion in future versions of USCDI
Criterion #1 Maturity - Current Standards
Level 2 - Data element is represented by a terminology standard or SDO-balloted technical specification or implementation guide.
Criterion #2 Maturity - Current Use
Level 2 - Data element is captured, stored, or accessed in multiple production EHRs or other HIT modules from more than one developer.
Criterion #3 Maturity - Current Exchange
Level 2 - Data element is electronically exchanged between more than two production EHRs or other HIT modules of different developers using available interoperability standards.
Criterion #4 Use Case(s) - Breadth of Applicability
Level 2 - Use cases apply to most care settings or specialties.
Please find attached Sound Generations' EnhanceFitness letter to express our support for the Physical Activity Alliance’s application to add Physical Activity Status as a data element to the next iteration of the U.S. Core Data for Interoperability (USCDI).
Please find attached Illinois State University's letter of support for the Physical Activity Alliance’s application to add Physical Activity Status as a data element to the next iteration of the U.S. Core Data for Interoperability (USCDI).
The American Heart Association supports the Physical Activity Alliance’s submission of the Physical Activity Status data element to standardize the assessment of physical activity (PA) into the U.S. Core Data for Interoperability (USCDI), including all four applicable standards addressing the components of aerobic and muscle strengthening PA. Each of these standards are validated in the peer-reviewed literature, are aligned with the 2018 U.S. Physical Activity Guidelines for Americans and correlate with the appropriate LOINC codes in HL7 FHIR Implementation Guide development. Evidence suggests that in clinics that regularly assess PA as a vital sign, patients are more likely to be referred to exercise programming which is health-promoting and important for prevention and chronic disease management across the lifespan. The AHA has been supporting the “It’s Time to Move” initiative by helping to convene experts, work with regulatory agencies, engage in the HL7 process, and manage the HL7 project work group calls for developing the Physical Activity FHIR Implementation Guide which will go to ballot in the May cycle. We encourage ONC to include the entire PA data element in the final version 4 of USCDI. If we can answer any further questions, please reach out to Paul Chase, Ph.D. (Paul.Chase@heart.org) or Laurie Whitsel, Ph.D. (Laurie.Whitsel@heart.org ).
The attached letter is being submitted on behalf of the Physical Activity Alliance to provide additional supporting information regarding the importance and growing popularity of assessing physical activity status among health systems.
Thank you for the opportunity to submit comments! Please find attached Tivity Health's letter to express our support for the Physical Activity Alliance’s application to add Physical Activity Status as a data element to the next iteration of the U.S. Core Data for Interoperability (USCDI).
This field is for general comments on this specific data element. To submit new USCDI data classes and/or data elements, please use the USCDI ONDEC system: https://healthit.gov/ONDEC
Official Website of The Office of the National Coordinator for Health Information Technology (ONC)
Submitted by Paige Denison on
EnhanceFitness LoS for Physical Activity Status to USCDI
Please find attached Sound Generations' EnhanceFitness letter to express our support for the Physical Activity Alliance’s application to add Physical Activity Status as a data element to the next iteration of the U.S. Core Data for Interoperability (USCDI).
Sound Generations EnhanceFitness LoS PAA Application PAS to USCDI.pdf