Background

The Physical Activity Alliance (PAA) is the nation’s largest and most inclusive community of physical activity advocates, researchers, academics, and practitioners. Representing physical activity and fitness technology, exercise professionals, athletic training, physical therapy, healthcare integration, public health, military readiness, corporate wellness, university recreation, adaptive fitness and disability access, PAA provides a broad-based voice for physical activity in the US. It leverages its deep expertise in policy and systems change, strategic planning, and workforce development to promote physical activity across the population. PAA advocates for policy and systems change primarily at the federal level across 10 sectors of the National Physical Activity Plan (NPAP), the road map for implementing the Physical Activity Guidelines for Americans. Despite abundant evidence about the importance of physical activity, our health system lacks standardized physical activity assessment, prescription and referral (US Department of Health and Human Services, 2018). As a result, millions of Americans lack appropriate counseling and prescription for active living to prevent or manage chronic diseases and their risk factors while improving mental health and well-being. In previous papers we have described the continuum of care that we aim to achieve as well as key steps necessary to achieve this standard (Whitsel et al., 2021).

It’s Time to Move is a multi-year, multi-pronged effort to address policy and systems changes to define, standardize, and integrate physical activity measures into the healthcare system and clinician workflows and connect patients to physical activity prescriptions that help them on their journeys toward active living. This work addresses regulatory change across multiple federal agencies and initiatives with non-governmental or quasi-governmental entities. These different entities and the role they have in this work are listed in the “Physical Activity Assessment, Prescription, and Referral Action Plan Key Stakeholders” section. It’s Time to Move will also connect the work in US healthcare with other policy and systems changes across other NPAP sectors (education, business/industry, community, military, fitness and parks, and sports) to support physical activity promotion and infrastructure. See Figure 1 for the road map of the It’s Time to Move work.

Immediate Next Steps

The immediate next steps for the It’s Time to Move initiative include:

1. Interacting with the Health Level 7 (HL7) community to develop a Fast Healthcare Interoperability Resources (FHIR) Implementation Guide. This will standardize measures for physical activity assessment, prescription and referral in a resource that will be publicly available and can be widely adopted and integrated into electronic health records and health system workflows. This work is well underway with the goal of publishing our first version of the Implementation Guide in August 2023. Not only will this measure standardization help improve patient care and treatment, but it will also provide, when implemented, a foundation for enhancing public health monitoring and surveillance systems to understand real-time physical activity levels across the population and analyze correlations between physical activity and patient health outcomes.

2. Engaging with the Office of the National Coordinator to have physical activity assessment incorporated into the US Core Data for Interoperability Standards (USCDI). USCDI is a standardized set of health data classes and constituent data elements for nationwide, interoperable health information data exchange. We achieved this goal when physical activity assessment was included in version 4 of USCDI published in July 2023.

3. Working with NCQA and CMS to develop the most-evidence-based performance and quality standards to incentivize health plans, health systems, and clinicians to integrate physical activity assessment, prescription and referral into patient care. This work is just underway and will continue over the next few years.

4. Communicating with the Centers for Medicare and Medicaid Services and the private payer community to seek coverage for physical activity prescriptions that connect patients to qualified exercise professionals, health coaches, and evidence-based programs. Work is underway with a consultant to develop a roadmap for payer engagement.

5. Engaging with the American Medical Association and the Digital Medicine Payment Advisory Group to develop the most appropriate CPT^™ codes for billing around the physical activity assessment, prescription and referral so the appropriate clinicians and qualified exercise professionals can be paid for their services.

6. Convening key stakeholders on a regular basis to keep these policy and systems changes moving forward. Sometimes, convenings with these key decision makers and change leaders may initiate progress outside of legislative and regulatory change.

Where We Go From Here

In the first year of a five-year plan, It’s Time to Move has made significant progress toward measure standardization and data exchange to enable physical activity data to flow within the US healthcare system and be exchanged with community-based organizations and professionals that can deliver a physical activity prescription. The PAA will continue to work on a stepwise path toward additional legislative, regulatory, and systems level change to foster implementation and uptake. We are working toward a future where it will be a standard part of clinical visits for patients to be asked about their physical activity levels, where clinicians are educated and empowered to provide a physical activity prescription and connect patients to resources in their community to support their journey toward active living. Future financial incentives will encourage providers to support active lifestyles for their patients. Imagine a world where we are a more active US population and we are equitably addressing patient health and well-being even more upstream to improve health outcomes for all.

Physical Activity Assessment, Prescription, and Referral Action Plan Key Stakeholders

National Committee for Quality Assurance (NCQA)

Works to improve healthcare quality through the administration of evidence-based standards, measures, programs, and accreditation. This is done by conducting administrative and patient surveys providing ratings and accreditations on the quality of commercial, Medicare, Medicaid and Exchange health plans, individual clinicians, and clinical practices.

It’s Time to Move is engaging with NCQA to add physical activity assessment, prescription, and referral quality and performance measures, which will incentivize insurers to cover and providers and health systems to implement guidelines based on best-practices.

National Quality Forum (NQF)

NQF is a measure-development organization which convenes patients, providers, and payers to create, evaluate, and publish metrics of what is considered “the gold standard for healthcare” in the US. The federal government and many private sector entities have engaged with NQF to endorse measures because of the rigor and consensus process behind them.

It’s Time to Move will engage NQF and other organizations to coordinate across performance and quality measures development work. Successfully doing so will incentivize CMS and private insurers to adopt the practice as a standard healthcare requirement, increasing patient coverage and provider use of physical activity assessment, prescription, and referral.

Agency for Healthcare Research and Quality (AHRQ)

AHRQ is a Federal agency under the US Department of Health and Human Services (HHS) charged with improving the safety and quality of healthcare for all Americans. They develop knowledge, tools, and data needed to improve the healthcare system and help consumers, healthcare professionals, and policymakers make informed health decisions. This includes managing the US Preventive Services Task Force (defined below), as well as conducting surveys that inform NCQA’s healthcare quality accreditation efforts.

It’s Time to Move engages AHRQ directly through USPSTF and indirectly through NCQA to integrate physical activity assessment, prescription, and referral services as a standard of high-quality healthcare.

Health Level Seven International (HL7®)

A not-for-profit, ANSI-accredited standards developing organization dedicated to providing a comprehensive framework and related standards for the exchange, integration, sharing, and retrieval of electronic health information that supports clinical practice and the management, delivery and evaluation of health services. HL7 collaborates with other standards developers, providers, payers, non-profits, and government agencies to develop standards for successful interoperability efforts.

It’s Time to Move works within the HL7 community to create, publish, and update a FHIR Implementation Guide that will standardize measures for physical activity assessment, prescription, and referral.

United States Preventive Services Task Force (USPSTF)

An independent, volunteer panel of national experts in disease prevention and evidence-based medicine convened by HHS’ AHRQ. The Task Force works to improve the health of people nationwide by making evidence-based recommendations about primary care preventive services. Insurers must provide full coverage for new and updated recommendations that receive an “A” or “B” grade from USPSTF one year after the latest issue date, beginning in the next plan year.

It’s Time to Move engages USPSTF to increase the scientific evidence base for physical activity assessment, prescription, and referral to make these practices the required norm of primary care and connect clinics to community level policy and systems changes that support active living. Physical activity counseling is currently included in five USPSTF clinical recommendations.

Community Services Preventive Task Force (CPSTF)

An independent panel in community preventive services, public health, health promotion, and disease prevention. The US Centers for Disease Control and Prevention provides scientific and administrative support to the CPSTF, and 32 liaison organizations representing federal agencies and non-profit organizations contribute perspectives and experiences needed to inform their work. The CPSTF provides evidence-based findings and recommendations about community preventive services, programs, and other interventions aimed at improving population health that are listed in The Guide to Community Preventive Services (“The Community Guide”)

It’s Time to Move engages with the CPSTF to review the scientific evidence base for community-based programs and services that support active living. Since 2005, the CPSTF has found evidence recommending 15 different physical activity interventions including Behavioral and Social, Campaigns and Informational, and Environmental and Policy Approaches.

Centers for Medicare and Medicaid Services Innovation Center (CMMI)

CMMI based out of the Centers for Medicare and Medicaid Services (CMS), a Federal agency under HHS tasked with administering Medicare, Medicaid, the Children’s Health Insurance Program, and the Health Insurance Marketplace. CMMI funds research and demonstration projects to build an evidence base for new payment and service delivery models. The Center’s priorities include designing models that are inclusive of a variety of providers who care for underserved populations and increasing beneficiaries’ access to high-quality care.

It’s Time to Move will engage the CMMI to increase the scientific evidence base for health and clinical practice regarding physical activity assessment, prescription, and referral. By funding pilot projects assessing what happens to patients after a physical activity referral, CMMI can help inform CMS coverage determinations for referral to evidence-based programs, qualified exercise professionals, and health coaches.

Patient-Centered Outcomes Research Institute (PCORI)

PCORI an independent, nonprofit research organization empowering patients and others with actionable information about their health and healthcare choices. The organization funds comparative clinical effectiveness research which compares two or more medical treatments, services, or health practices to help patients and other stakeholders make better informed decisions.

It’s Time to Move will engage PCORI to expand the evidence base for clinical effectiveness of physical activity assessment, prescription, and referral. This connects closely to our work with CMMI as a means of developing scientific evidence to inform physical activity prescription and referral coverage determinations.

American Medical Association (AMA)

AMA is a national association representing American physicians to remove obstacles interfering with patient care, prevent chronic disease and confront public health rises, and drive the future of medicine. AMA regularly issues, maintains, and updates the CPT® Codes registry to accurately reflect current clinical practice and innovation in medicine.

It’s Time to Move works closely with AMA to annually develop and update CPT® Codes that support physical activity assessment, prescription, and referral.

Centers for Medicare and Medicaid Services (CMS)

The HHS agency which administers the nation’s major public healthcare programs. CMS’ Health Information and Policy Group helps drive adoption of HL7® (defined below) standards through policy making, including the Interoperability and Patient Access (2020) which adopted the HL7® standards for FHIR-based APIs as the IT-backbone of the US healthcare system.

It's Time to Move will engage CMS around coverage determinations for evidence-based programs and delivery of supervised exercise therapy for patients who are diagnosed with physical inactivity and chronic disease risk factors.

Office of the National Coordinator for Health Information Technology (ONC)

Located within the HHS Office of the Secretary, ONC is the principal federal entity charged with coordinating nationwide efforts to implement and use the most advanced health information technology, including HL7® standards. This includes maintaining the US Core Data for Interoperability (USCDI), a standardized set of health data classes and constituent data elements for nationwide, interoperable health information exchange.

It’s Time to Move is engaging ONC with to add “physical activity status” as a health assessment in USCDI, which is currently a “Level 2” data element for the USCDI draft Version 4 (2023).

Healthcare Information and Management Systems Society (HIMSS)

A nonprofit organization that works to optimize the use of technologies in a healthcare setting. Its stated goals are related to improving both safety and quality of healthcare delivery, as well as access and cost management. HIMSS also manages the Electronic Health Record Association (EHRA), a trade association of EHR companies addressing national efforts to create interoperable EHRs.

It’s Time to Move leverages HIMSS’ convening power of key EHR stakeholders to connect different vendors in the HL7® measure development process, where they can troubleshoot technical interoperability challenges between their different systems.

United States Registry of Exercise Professionals® (USREPS®)

An internationally recognized registry of all exercise professionals in the US organized and maintained by the Coalition for the Registration of Exercise Professionals® (CREP®). USREPS® registrants hold National Commission for Certifying Agencies (NCCA)-accredited exercise certifications, qualifying them to lead individuals and organizations in the adoption and maintenance of active, healthy lifestyles.

It’s Time to Move works with USREPS® to give providers a simple, reliable resource for referring patients to qualified physical activity professionals.

Key Terms

Physical Activity Assessment

The process of a healthcare provider asking standardized questions about a patient’s physical activity frequency and duration. For example: “On average, how many days per week do you engage in moderate to vigorous physical activity (like a brisk walk)?” and “On average, how many minutes do you engage in physical activity at this level?” The days and minutes indicated are multiplied to assess whether the patient is meeting the recommended 150 minutes of moderate-to-vigorous physical activity each week.

Physical Activity Prescription

A written prescription from a healthcare provider for safe and effective physical activity aligned with the Physical Activity Guidelines for Americans1. Physical Activity Referral: A referral to a professional offering physical activity counseling, such as a physiotherapist, clinical exercise physiologist, or certified fitness instructor.

Electronic Health Record (EHR)

A patient-centered record which makes information available instantly and securely to authorized users. EHRs contain patients’ medical and treatment histories that can be shared with healthcare providers across organizations. This allows health information, including the results of a physical activity assessment, to seamlessly be exchanged between all health professionals involved in a patient’s treatment.

Current Procedural Terminology® Code (CPT® Code)

CPT Codes are used to report healthcare providers’ services and procedures for payment. When a claim is filed with the CPT procedure code and appropriate diagnosis code (ICD-10), a payment is made to the provider. There are currently 42 CPT® Codes concerning physical activity assessment, prescription, and referral, all of which can be found on PAA’s Website.

Fast Healthcare Interoperability Resource® (FHIR®)

An HL7® (defined below) specification for exchanging healthcare information electronically between different computer systems regardless of how it is stored in those systems. FHIR has been recognized by CMS (defined below) as the foundational standard to support data exchange via secure application programming interfaces (APIs), and is now the required technology for payers and providers to exchange healthcare information to improve patients’ access. It’s Time to Move is convening diverse health IT stakeholders to develop a shared set of measures for physical activity assessment, prescription, and referral in FHIR to facilitate mass-adoption of these services.

Acknowledgements: A huge thanks to Griffin Barriss for his contributions to this work as we prepared for the Active Living Conference presentation. Also, to David and Mary Bernauer for their individual financial contribution to our HL7 engagement.

Correspondence should be addressed to:

Laurie Whitsel, Ph.D.

National Vice President – Policy Research/Senior Advisor

American Heart Association/Physical Activity Alliance

1150 Connecticut Avenue – Suite 300

Washington, DC 20036

laurie.whitsel@heart.org

Laurie Whitsel: 0000-0003-3896-7471

Amy Bantham: 0000-0001-9276-3512

Conflict of Interest Statement:

We have no conflicts of interest to disclose.

Creative Commons License:

This work is licensed under a Creative Commons Attribution-Noncommercial 4.0 International License (CC BY-NC 4.0).