This page defines the mechanisms providers can use to assist patients with their physical activity levels if measurements indicate that intervention is called for. There are three main mechanisms defined:

• creating exercise prescriptions detailing what level of physical activity a patient should performing on a regular basis
• setting plans and goals with the patient and their supports around what their physical activity level should look like - and how they can realistically get there, and
• creating referrals to physical activity specialists who can help a patient to achieve their physical activity targets in a manner that meets their physical limitations, lifestyle and interests

Practitioners can use these three types of interventions separately or in concert to help patients achieve a healthy level of physical activity.

Exercise Prescriptions

Sometimes all that is necessary to help a patient to improve their level of physical activity is to have their clinician formally prescribe it, in much the same way as they might prescribe a medication or physiotherapy. The research supporting the benefits of prescribing exercise are described in more detail on the background page.

In FHIR, orders for physical actions are represented using the ServiceRequest profile. (This is the same profile as is used for referrals - see below for differences in usage.)

In the case of an exercise referral, the ServiceRequest 'performer' would be the patient themselves. The requested activity would be "exercise therapy" (SNOMED 229065009), possibly with more specific textual details as to the type of physical activity to perform, along with timing information - e.g. 150 minutes/week conveyed in the effectiveTiming element.

While in many cases there is no need for such orders to be exchanged electronically, it may be useful for others, particularly physical activity service providers involved in the patient's care to be aware of the existence of the order so they can support the patient in performing it. Therefore, this specification supports the electronic retrieval of exercise prescriptions by both Service Provider and Patient Engagement systems.

Plans and Goals

A key step in improving a patient's physical activity levels are establishing and monitoring against goals for a desired level of physical activity and agreeing on a plan to attain that level of activity. In some cases, these might be established and maintained only in the system of the care manager and merely be retrieved by the Service Provider and Patient Engagement systems. However, in some environments, Referral Recipients and/or patients themselves might be able to create and/or update goals and update care plans. This standard supports these actions but leaves it to organizational policy which types of actions can be performed by which users. Even if updating is permitted, there may be limitations on which elements can be changed. (For example, changing the 'subject' of a goal or care plan typically will not be allowed by anyone, with the possible exception of technical staff at a provider site who manage patient merges and splits or otherwise addressing record errors.

In this implementation guide, both goals and plans are relatively simple, with only a small subset of the potential data elements expected to be supported. These expectations are reflected in the physical activity goal and care plan profiles. Systems are free to support additional data elements, but cannot presume that other participants will also support them without site-specific negotiation.

The purpose of the CarePlan resource is to allow a shared understanding of what actions the patient (and those around them) will take to help improve their level of physical activity. Systems may express this as simple narrative. The plan can be updated to reflect changes based on patient need and on what's working - or is not working.

Goals allow a shared understanding of a target level of physical activity. These might be ongoing goals to be sustained or might be target goals to be achieved by a particular point in time. Over time, goals may change their state, to reflect progress as well as whether they are considered an 'active' goal or not. This information might be reflected by the patient, a physical activity professional and/or their care manager.

Details on how goals and plans are created, updated and shared are covered on the Workflow page of this IG.

Choosing between Exercise Prescriptions and Plans

To a certain extent, a plan and an exercise referral serve similar purposes - practitioners can use both to set an expectation for a patient to achieve an improved level of physical activity. In some cases, an implementer might choose to use only one of the two. Key differences between them (which may help determine whether you need one, the other, or both) are as follows:

• Exercise referrals are formal orders - though they are orders targeted to the patient themselves, rather than another provider. Plans represent guidance/recommendations but are not formal orders.
• Exercise prescriptions are 'static'. Practitioners write them once, but after that the orders typically do not change, beyond eventually being marked as completed or cancelled. Plans, on the other hand, are dynamic. They may be updated and revised numerous times as circumstances change.
• Exercise prescriptions can only be created or changed by appropriately qualified practitioners. Plans can be created or changed by anyone, potentially including the patient themselves.
• Exercise prescriptions will typically set specific objectives for what is to be done but will be limited in description or detail. For example, "Work towards an average of 10,000 steps per day, and at least 3 days of 20 minutes' worth of strength exercises". On the other hand, plans will often provide much more detail, including descriptions of how, why, interim milestones, conditionality, etc. A plan may have multiple paragraphs and may include computable goals that can be used as targets.
• An exercise prescription has a single status - it can be draft, active, on hold, cancelled or completed. On the other hand, each step within a plan and each goal can have its own status to track completion, degree of success and notes around how things are going.
• Because of these characteristics, plans will often take more time and effort to create and to manage. They are therefore more likely to be used by practitioners who are more heavily engaged and focused on the patient's exercise progress.

Referrals

Referrals are the process by which one practitioner asks another practitioner to provide a type of care for a patient. In the case of this implementation guide, this will be the Care Manager seeking the services of a Service Provider. In cases where a Referral Recipient delegates and solicits care from a different Service Provider, then for the purposes of this implementation guide, they take on the role of being a Care Manager. (Some insurers or other programs may place limits on what types of practitioners they consider to be authorized to create referrals. This implementation guide does not establish such limitations.)

Referrals could be issued for a wide range of services to help a patient improve their physical activity level:

• physiotherapy to help address physical limitations in performing exercise,
• assessment of a patient's capabilities and personal tastes to develop a tailored exercise program that works well for the patient's abilities and interests,
• training programs to help a patient understand how to perform certain types of exercise safely and effectively,
• ongoing coaching to help provide motivation, correction and adjustment of exercise plans based on patient needs, and/or
• enrollment in group programs that support any or all the above.

The high-level list of candidate codes for types of interventions that can be ordered is found here. However, additional detail can be provided with text and, by mutual agreement, more detailed codes. The set of codes defined in this implementation guide will evolve based on implementer feedback.

The referral process consists of two steps: the referral 'authorization' and the actual request for the desired practitioner to satisfy the authorization.

The first step must be done by an 'authorized' practitioner - someone who has the training and often the licensure to determine that a particular service is necessary and appropriate. They document the service to be performed, who it is to be delivered to, the timeframe in which it is to be delivered, and any other instructions. For physical activity-related services, this will always be a ServiceRequest resource corresponding to the Physical Activity Referral profile.

The beneficiary of the service will typically be the patient, but in some cases, it might be some other caregiver who assists the patient. For example, providing counselling or training to a spouse or other family member who can assist the patient in their physical activity.

The service and timing of the service are encoded to allow some degree of automated computability (to help find who can perform the service, to decide whether the targeted performer can deliver the service in the desired timeframe, and perhaps most importantly, to determine whether the service is covered by insurance). However, additional detail can be provided in free text.

The second step is conducted using a Task resource that adheres to the SDOH Task profile. The task is used for the conversation where the Care Manager asks the Service Provider "Can you please satisfy this referral?" and the Service Provider has the option of responding 'yes' or 'no' and eventually reporting back on how things went. This step might be initiated by the same practitioner who created the referral, but quite often this 'dispatching' process is managed by nurses, receptionists or other back-end staff.

A key distinguishing feature of the 'Task' portion of the workflow is that fulfillment of the same order might be sought more than once. For example, initially a Task might be directed to Service Provider A, who refuses the task because of availability issues or because they no longer provide the desired service. A new Task (pointing to the same ServiceRequest) might then be spawned seeking fulfillment of the referral by Service Provider B. Service Provider B might initially accept the referral but then later cancel because the service provider moves locations. Finally, a third Task might be created seeking fulfillment by Service Provider C who accepts and delivers the needed service. Only when that third Task is completed, and the ordering clinician is satisfied that their objectives have been satisfied, would the original ServiceRequest be marked as 'completed'.

Further details describing the specific processes involved in creating and sharing referrals can be found in the Workflow section of this implementation guide.

Exercise prescriptions use exactly the same profile as referrals. However, the usage is different in two ways:

• 'Exercise prescriptions' will always have a ServiceRequest.performer of the Patient. Referrals will either be non-directed (no performer specified, as performer is selected at the dispatching phase) or be targeted to a Practitioner or Organization.
• There is no 'Task' resource involved with an exercise prescription as there is no need to solicit a practitioner to see if they can fulfill the prescription. The assignment to the patient (and acceptance) occurs as part of the interaction between the ordering provider and the patient.

Intervention Summaries

The objective of a referral is always to have a service (or perhaps a set of services) performed. In FHIR, physical activity- related interventions would be represented using the Procedure resource. However, the workload involved in having the Service Provider system capture each counselling session, visit to a fitness class, etc. has been deemed too high and the value to the ordering clinician too low to mandate the capture of detailed procedure information as part of this IG. Instead, the expectation is that, in most cases, the practitioner or organization that accepts the referral will prepare a 'report' that summarizes the interventions performed, progress made, etc.

The summary is expressed using the PA Intervention Report. It captures a PDF document that summarizes key information about an exercise professional's engagement with a patient. Possible content might include assessments, strategies tried, participation level/attendance, recommendations, etc. The report can also link to any key measurements (e.g. starting and finishing physical activity level, exercise sessions that exemplify some of the narrative in the report, etc.)

The key points that SHOULD be covered in an intervention summary are:

• Were the issues that were intended to be addressed by the referral fully addressed? E.g. Does the patient now have what they need in order to maintain appropriate physical activity levels on an ongoing basis?
• If there are outstanding issues that were not able to be fully addressed, what issues remain and what were the barriers that kept them from being addressed?
• If the referral was to a specific exercise program, what level of participation did the patient engage in?
• What is the plan that the patient has been left with and what next steps (if any) are recommended for the ordering clinician to take to continue to support the patient?