Physical Activity Implementation Guide
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Physical Activity Implementation Guide, published by HL7 International - Patient Care WG. This is not an authorized publication; it is the continuous build for version current). This version is based on the current content of and changes regularly. See the Directory of published versions

Importance of Physical Activity

For many readers, the notion that physical activity is important to healthcare outcomes, and that prescribing increased physical activity will improve healthcare outcomes may be taken as a given. However, for those who are interested in some of the supporting research (perhaps to help make the case for implementing this implementation guide in their own organization), this page provides more detail about existing evidence, complete with citations.

NOTE: These references are largely U.S.-centric, however the conclusions are generally applicable to other countries, though the statistics may differ somewhat.

Physical Activity and Health

Being regularly physically active is one of the most important health behaviors people can engage in to maintain physical health, mental health, and well-being.1 Regular physical activity (PA) is both health-promoting and important for disease treatment and prevention with numerous benefits that contribute to a disability-free lifespan.2 New research shows that more than 110,000 lives could be saved annually if adults in the U.S. increased their physical activity by just ten minutes per day.3 Physical activity reduces the risk of several of the leading causes of death and disability, including cardiovascular disease and colon, breast, and endometrial cancers.4 Physical activity is also important for improving outcomes for the approximately 2/3 of Americans who have a chronic condition. For example, physical activity improves survival from breast cancer5 and several aspects of quality of life for a broader range of cancers.6 Despite the many benefits of physical activity, we know that youth physical activity decreased during the COVID-19 pandemic.7 The overall prevalence of physical inactivity among adults in our nation is alarmingly high (25.3 percent), and significant disparities exist among race/ethnic groups (e.g., non-Hispanic Asian adults, 20.1 percent; non-Hispanic White, 23.0 percent; non-Hispanic American Indian/Alaska Native, 29.1 percent; non-Hispanic Black, 30.0 percent; and Hispanic adults, 32.1 percent).8

A woman holding an exercise ball being coached by a man

A recent systematic review has shown convincingly that physical activity significantly reduces the risk of more severe clinical outcomes in those infected with severe COVID.9 Recent studies show that PA is associated with strong immune response, risk reduction from community-acquired infectious disease and mortality, and increased vaccine potency.10, 11, 12 It also contributes to social connectedness, quality of life, and environmental sustainability.13 Currently in the U.S., only 26 percent of men, 19 percent of women, and 20 percent of adolescents report sufficient activity to meet the relevant guidelines for aerobic and muscle-strengthening activities.1 Even so, current population PA levels avert 3.9 million premature deaths globally and 140,200 premature deaths in the U.S. on an annual basis.14

If all Americans met current physical activity guidelines, Medicare could save $73.9 billion per year.15 In one study of older adults including over 50,000 patients, total average healthcare expenses were significantly reduced by 16% for fitness program participants compared to non-participating Medicare Advantage members. The study's findings showed total annual average health expenses, including medical and pharmacy, among program participants to be $4,463 compared to $5,303 for non-participants. Medical component of costs was decreased by 26%, driven primarily by reductions in hospitalization costs. Use of outpatient care was higher for participants combined with less acute care, indicating better health management among participants compared to non-participants. Participants also performed significantly better on key quality measures including all-cause 30-day readmissions, adherence to hypertension and cholesterol medications, diabetes care (HbA1c testing and eye exams), and many preventive screening measures including colonoscopy, depression, cholesterol, breast cancer, and prostate cancer screening when compared to non-participants.16

Low PA and low fitness also pose immediate and long-term threats to our nation’s safety and security. At this time, 71 percent of Americans ages 17-24 fail to meet core eligibility requirements for entrance into the military, creating a serious recruiting deficit.17 Among those who do meet basic requirements for service, musculoskeletal injuries associated with low fitness levels have costed the Department of Defense hundreds of millions of dollars,18 and have been identified as the most significant medical impediment to military readiness.19

Importance of Measuring Physical Activity

Despite the abundance of evidence on the importance of physical activity for individuals of all ages, races and abilities,1 our current healthcare system lacks a set of standardized measures for physical activity that can be incorporated into electronic health record (EHR) systems and easily utilized by healthcare clinicians.2 As a result, millions of Americans lack appropriate counseling and prescription for active living that would not only prevent or manage most of the chronic diseases and their associated risk factors, but also improve mental health and well-being.

Improving population levels of physical activity requires comprehensive efforts to maximize the potential benefits of setting-specific interventions under a coordinated multilevel approach across the healthcare system and community and home-based resources.20, 21 Numerous guidelines and recommendations, including the Physical Activity Guidelines for Americans,22 the US Preventive Services Task Force,23 the Healthy People 2030 Framework,24 and the US National Physical Activity Plan25 promote the importance of PA screening, assessment, and prescription as a standard of care in clinical practice.

In response to common barriers to effectively deliver complex PA counseling solely in clinical settings, programs have integrated referral of patients to community-based physical activity resources and programs.21 These exercise referral schemes have also shown effectiveness.26, 27 Compared with usual care, more patients who received referrals for exercise by their primary care providers achieved PA recommendations (relative risk, 1.16), and experienced reduced depression.27 Heath and colleagues28 examined the feasibility of a clinic-based Physical Activity Vital Sign (PAVS) assessment and referral protocol to YMCA exercise programming compared with PAVS alone in a sample of adult patients seen for primary care visits in a southeastern US health system. They found improvements in self-reported PA after 12 weeks in the PAVS plus referral group (P<0.02). The specific exercise vital sign measure proposed for this implementation guide has been tested and found to correctly identify the majority of adults who do and do not meet physical activity guidelines.29 Other meta-analyses and systematic reviews have shown that physician counseling (odds ratio, 1.42; 95% confidence interval, 1.17–1.73) and exercise referral systems (risk ratio, 1.20; 95% confidence interval, 1.06–1.35) promote improvements in patients’ PA for up to 12 months.26, 30, 31

People of varying age in a fitness room holding a yoga pose


  • 1. US Department of Health and Human Services. Physical Activity Guidelines for Americans, 2nd edition. 2018.
  • 2. Wen CP and Wu X. Stressing harms of physical inactivity to promote exercise. Lancet. 2012;380:192-3.
  • 3. Saint-Maurice, PF., Graubard, BI., Troiano, RP., Berrigan, D., Galuska, DA., Fulton, JE., Matthews, CE. Estimated number of deaths prevented through increased physical activity among US adults. JAMA Intern Med. 2022 March 1; 182(3); 349-352.
  • 4. American Institute for Cancer Research/ World Cancer Research Fund. Continuous Update Project: Physical Activity. 2020. Available at
  • 5. American Institute for Cancer Research/ World Cancer Research Fund. Continuous Update Project: Breast Cancer Survivorship. 2020. Available at
  • 6. Rock, CL., Thomson, CA., Sullivan, KR., et al. American Cancer Society nutrition and physical activity guideline for cancer survivors. Ca Cancer J Clin 2022;
  • 7. Grimes, A., Lightner, JS., Eighmy, K., Steel, C., Shook, RP., Carlson, J. Decreased physical activity among youth resulting from COVID-19 pandemic related school closures: Natural experimental study. JMIR Form Res.2022 Apr; 6(4):e35854.
  • 8. Centers for Disease Control and Prevention. Adult physical inactivity prevalence maps by race/ethnicity. January 2022. Atlanta, GA. Accessed online June 17, 2022 at Adult Physical Inactivity Prevalence Maps by Race/Ethnicity | Physical Activity | CDC
  • 9. Hill, AL., Whitfield, G., Morford, M., Okasako-Schmucker, DL., et al. Brief summary of findings on the association between physical inactivity and severe COVID-19 outcomes. Centers for Disease Control and Prevention. Atlanta, Georgia. 2022.
  • 10. Nieman DC, Wentz LM. The compelling link between physical activity and the body’s defense system. J Sport Heal Sci. Published online 2019. doi:10.1016/j.jshs.2018.09.009.
  • 11. Hamer M, Kivimäki M, Gale CR, David Batty G. Lifestyle risk factors, inflammatory mechanisms, and COVID-19 hospitalization: A community-based cohort study of 387,109 adults in UK. Brain Behav Immun. Published online 2020.
  • 12. Dixit S. Can moderate intensity aerobic exercise be an effective and valuable therapy in preventing and controlling the pandemic of COVID-19? Med Hypotheses. Published online 2020.
  • 13. Global Advocacy Council for Physical Activity International Society for Physical A and Health. The Toronto Charter for Physical Activity: A Global Call for Action. J Phys Act Health. 2010;7 Suppl 3:S370-85.
  • 14. Strain T, Brage, S., Sharp, SJ., Richards, J., Tainio, M., Ding, D., Benichou, J., Kelly, P. Use of the prevented fraction for the population to determine deaths averted by existing prevalence of physical activity: a descriptive study. Lancet Global Health. 2020;8:e920-30.
  • 15. HHS FY2016 Budget in Brief,
  • 16. SilverSneakers Program Impact Analysis, independent study conducted by the Health Economics and Advanced Analytics Practice at Avalere Health on behalf of Tivity Health, March 2021.
  • 17. U.S. Department of Defense, Joint Advertising Market Research and Studies. (2016). The target population for military recruitment: youth eligible to enlist without a waiver.
  • 18. Bulzacchelli M, Sulsky S, Zhu L, Brandt S, Barenberg A. The cost of basic combat training injuries in the U.S. Army: injury-related medical care and risk factors. In: Military Performance Division, U.S. Army Research Institute of Environmental Medicine. Edited by Natick MA, March 2017.
  • 19. Hauret KG, Jones BH, Bullock SH, Canham-Chervak M, Canada S. Musculoskeletal injuries description of an under-recognized injury problem among military personnel. AmJ Prev Med. Jan 2010; 38(1)(suppl):S61–S70.
  • 20. Vuori IM, Lavie CJ, Blair SN. Physical activity promotion in the health care system. Mayo Clin Proc. 2013;88:1446–1461. doi:10.1016/j.mayocp.2013.08.020.
  • 21. Lobelo, F., Rohm Young, D., Sallis, R., Garber, MD., Billinger, SA., Duperly, J. Hutber, A., Pate, RR., Thomas, RJ., Widlansky, ME., et al., Routine assessment and promotion of physical activity in heathcare settings: A scientific statement of the American Heart Association. Circulation. 2018. 137(18):e495-e522.
  • 22. US Department of Health and Human Services. Physical Activity Guidelines for Americans, 2nd edition. 2018.
  • 23. US Preventive Services Task Force. Draft Recommendation Statement on Behavioral Counseling to Promote a Healthy Lifestyle in Adults with Cardiovascular Risk Factors. 2020.
  • 24. Office of Disease Prevention and Health Promotion. US Department of Health and Human Services. Healthy People 2030 Framework. 2020.
  • 25. National Physical Activity Plan. 2016. National Physical Activity Plan - PAA (
  • 26. Williams NH, Hendry M, France B, Lewis R, Wilkinson C. Effectiveness of exercise-referral schemes to promote physical activity in adults: systematic review. Br J Gen Pract. 2007;57:979–986. doi:10.3399/096016407782604866.
  • 27. Pavey TG, Taylor AH, Fox KR, Hillsdon M, Anokye N, Campbell JL, Foster C, Green C, Moxham T, Mutrie N, Searle J, Trueman P, Taylor RS. Effect of exercise referral schemes in primary care on physical activity and improving health outcomes: systematic review and meta-analysis. BMJ. 2011;343:d6462.
  • 28. Heath GW, Kolade VO, Haynes JW. Exercise Is Medicine: a pilot study linking primary care with community physical activity support. Prev Med Rep. 2015;2:492–497. doi:10.1016/j.pmedr.2015.06.004.
  • 29. Kuntz, J. L., Young, D. R., Saelens, B. E., Frank, L. D., Meenan, R. T., Dickerson, J. F., Keast, E. M., & Fortmann, S. P. (2021). Validity of the Exercise Vital Sign Tool to Assess Physical Activity. American journal of preventive medicine, 60(6), 866–872. doi:10.1016/j.amepre.2021.01.012
  • 30. Sanchez A, Bully P, Martinez C, Grandes G. Effectiveness of physical activity promotion interventions in primary care: A review of reviews. Prev Med. 2015;76(suppl):S56–S67. doi:10.1016/j.ypmed.2014.09.012.
  • 31. Orrow G, Kinmonth AL, Sanderson S, Sutton S. Effectiveness of physical activity promotion based in primary care: systematic review and metaanalysis of randomised controlled trials. BMJ. 2012;344:e1389.