Now Reading: Adding the Newest Vital Sign to EHRs- Exercise – is Validated

The next several days’ worth of posts are going to be devoted to physical activity, and more specifically to walking. This is in prep for a walking summit I am participating in (and will be social media-ing) at the Kaiser Permanente Center for Total Health (@kptotalhealth) next week. The timing actually has less to do with the recent calorically dense holiday than it does with hurricane Sandy, which postponed the summit until next week…

This study was publicized in the middle of last month (you can read the press release here) and shows the impact of making a change in medicine that happens in a generation (or less) – adding a new vital sign. As the title implies, this one is called the exercise vital sign (EVS for short), and has been part of the Kaiser Permanente Southern California health system since 2009 (and connected to the multi-organizational Exercise is Medicine campaign), and embedded in the electronic health record. It’s the perfect illustration of what I’ve been saying/tweeting/hashtagging – “Prevention is the new HIT.”

The study is a quantitative analysis of the EVS activity, patient characteristics, and comparison to national surveys, to test its validity. And, it passes.

In the study period from 2010-2011, there were 1,793,385 adult patients with an outpatient visit at Kaiser Permanente Southern California, and 1,537,798 or 86 percent, had an EVS recorded. This demonstrates that it’s now part of care, part of the electronic health record, part of the vital signs section of the encounter.

Statistics comparing the patients who had an EVS to national surveys shows that there is a lower reported physical activity % in this population (30 % vs 50 – 60 % in the national assessments). There are lots of reasons detailed for this, including the makeup of the Southern California population and the wording of the standardized question. The reason that I am most intrigued by, though is that EVS is asked by the patient’s health care provider rather than a research assistant, as happens in the national surveys.

I think the locus of the question being asked is extremely important – being asked right before you see your doctor creates a different set of actions than being asked by a research assistant at your front door. And, it changes the medical visit, as Dr. Bob Sallis discusses below.

Speaking of changing, this not only changes the medical visit, it changes the perspective of the medical profession itself, from focusing on health care to total health. I have been told anecdotally by patients that initially their physicians handled discussion of the numbers awkwardly, but this is changing. I have also been told that one of the biggest impacts was on the staff asking the questions, who learned that their physical activity could be improved, too. Interesting what happens when you start measuring things that patients do outside of the medical office…

Adding this vital sign is a great innovation, it should be part of every electronic health record system, and there are many people willing to help make this a standard across health care. My awesome colleague Kristen Andrews (@ldsklandrews) posted a helpful blog series on how to implement EVS in medical practices. If we want the health system to take physical activity seriously, its measurement should be as important as anything else we measure, such as blood pressure. By the time you read this, millions of patients will have already reported their EVS into an electronic health record, so it’s being done successfully, and now with scientific validity.

If you have questions about the measure or how to implement it into your practice or in your health care, feel free to post in the comments and I’ll get answers for you. Prevention is the new HIT.

Tomorrow… from the medical office to the built environment – how walking can be supported.


Ted,  One critical factor in the high utilization of the Kaiser PHR (60% +) is that you have a closed network of providers and almost all the care occurs within the Kaiser system.  Thus, patients only have to access one, integrated patient portal.
However, Kaiser is atypical. About 5% of the U.S. population is in a highly integrated system similar to Kaiser.
The more typical situation is a “leaky” network of providers — patients go across systems to doctors and hospitals with few boundaries.  The Medicare ACO model is built on the premise of patient choice being more important than network and referral management.
I’m already hearing anecdotes “My mom has 5 patient portals with 5 different doctors”. This non-integrated, tethered PHR clearly is suboptimal and IMHO is destined for failure.

VinceKuraitis Hello Vince, You commented on another important study – validating exercise as a vital sign, not the one you intended to comment on, I’ll copy your comment over there and tweet you the link to my response to continue the dialogue,

I’ve been interested in the possibility of giving out “Walking Prescriptions”. Kaiser is sponsoring a trial in San Diego and Beth Israel Deaconess has a checklist for readiness website as well.
I’m wondering if a simple prescription pad given to patients with an EveryBodyWalk could work. What do you think?

MarkHarmel1 Hi Mark, When it comes to encouraging physical activity, I ask a different question – do you think it’s going to hurt anyone to try it? 
And the answer usually is…. probably a lot less than some of the other things we prescribe. You can find a ton of resources at the website, including customized prescriptions, as well as
So I say no need to ask, give it a try, post your results back here?

Ted Eytan MarkHarmel1 The Exercise is Medicine Rx pad is a good start. It could also look more fun  – perhaps with the EveryBody Walks feet in a corner and inspiring quote.

Ted Eytan, MD