Setting a Standard for Exercise and Physical Activity Promotion

Family medicine researcher hopes to inform a foundation for standardized exercise documentation

Danica Erickson, Department of Family Medicine - 17 September 2019

The Canadian Society for Exercise Physiology recommends 150-minutes of moderate-to-vigorous physical activity every week to maintain good health. As well, there is overwhelming evidence to suggest that exercise is effective in preventing and treating many chronic diseases and conditions, which are often managed by family doctors. But Canadian family physicians' knowledge of exercise prescription, their notation of exercise in electronic medical records (EMR), and their perceptions and management of this aspect of health are not well-known. Cliff Lindeman, a DoFM staff member working with the Alberta Strategy for Patient Oriented Research (SPOR) Primary and Integrated Health Care Innovation Network (PIHCN) and a PhD Student in Behavioural Medicine, is undertaking research in order to present a clearer picture of how exercise is prescribed and tracked by physicians.


Lindeman, who began his career in kinesiology, became interested in this topic when a data manager with the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) mentioned to him that family physicians' EMR exercise information is extracted by CPCSSN. Lindeman asked for an overview of the 'exercise field' and noticed that it is often grouped with other lifestyle factors such as smoking and sleep information. The exercise-related entries included both exercise and physical activity status, which Lindeman points out are two different things; exercise is a planned and deliberate physical activity to maintain or improve physical fitness while physical activity also includes basic day-to-day movement. The nature of exercise inputs in EMR were found to be primarily open-text, unstructured entries; "The most frequent entries in the risk factor exercise field in Southern Alberta, are short comments including 'no', 'yes', 'walks', and 'walking'." he says. However, these physicians' brief notations did not provide insight into the nature of the questions physicians are asking patients.


In order to generate an accurate description of current practice behaviour, Lindeman's research consists of three separate but related research studies:

A content analysis of a representative, random sample of inputs in the national CPCSSN dataset (~1.7 million patients) to determine the nature of information extracted from the available data. Some content, such as Subjective Objective Assessment Planning (SOAP) notes in EMRs, contain potentially identifiable information and thus is not extracted for privacy reasons. He is asking a number of questions. "In the information CPCSSN does extract, what do we know about exercise information physician's record and how often are physicians recording this information?" CPCSSN includes data from many EMR templates that differ in both structure and format, so, "Does the quality of care vary based on which EMR individual family physicians choose to use? Do only some EMR have a text box to record patient exercise?" A scoping review he completed found that it is common for research studies to utilize unstructured or open-text exercise data from family physician EMRs, and that the action a physician gave advice is noted, but there is often little detail about the nature of that advice and whether follow-up occurred. There was also limited information about whether or not physicians refer to exercise guidelines in related conversations with patients.


His second study will investigate Canadian medical schools' curriculum related to exercise. "A bit to my surprise, I haven't identified any articles or reviews that look at exercise training in medical schools across the country. Many of the existing exercise training interventions for physicians are based on Exercise is Medicine Canada, which is a series of programs and resources. But it appears that medical schools have not imbedded this content into course work. Rather, these programs appear to be 'extra', non-required training". Lindeman will connect with all 17 Canadian medical schools and family medicine residency programs to determine if their curriculum includes exercise guidelines and related strategies for patient communication, the importance of exercise documentation in EMR, and best practices for follow-up. It is important that physicians have the skills to approach the topic of exercise tactfully and then seek permission from their patients to have the required conversations. Lindeman points to studies that determined physicians who took exercise prescription training reported feeling more confident and knowledgeable about having related conversations with patients; unless medical students and residents have specific interests in this subject, they may not have the required confidence and knowledge.


Lindeman's third study will be a survey of a representative sample of southern Alberta physicians who are CPCSSN sentinels, to identify via Theory of Planned Behaviour social norms, attitudes, and perceived behavioural control in exercise fields in EMR. "By surveying a random set of physicians and then comparing behavioural constructs to what they have recorded about exercise and how they have recorded it, factors that may predict what happens in practice should emerge". This exploration could identify what physicians see as valuable in their patient discussions about physical activity and how this relates to clinical practice.


Lindeman's research will support his PhD dissertation, but he also hopes the findings will start a conversation about physicians' ease in confidently addressing the subjects of exercise and physical activity with patients, with the ultimate goal of decreasing the incidence of preventable chronic illnesses. "Describing the content and location of exercise documentation in EMR as outlined in the three studies is only the first step. The next step is to pattern-match to the national CPCSSN dataset to determine if a 'physical inactivity' case definition can be validated. Ideally physicians could then easily access a report of inactive patients who are not meeting exercise guidelines in order to encourage a meaningful conversation about exercise".