Primary Care Provider Best Suited to Handle PPE

The Preparticipation Physical Evaluation (PPE) is not just the preseason “sports physical.” Gone are the days of the “if you have a pulse, you can play” mentality being acceptable. The overarching objective of this PPE is to identify conditions that can predispose students for serious injury or death as well as signify their physical readiness to participate in their sport of choice.

Efforts to enhance and optimize this screening process have continued to evolve since at least 1983 and is considered an important component of student safety. The most recent 5th edition of the PPE was published in 2019 and is in the process of being updated with a release planned for the fall of 2026. The goals of the PPE are the following:

• Promote optimal and safe physical activity.

• Provide a framework to assess, promote and discuss physical and psychological health related to physical activity in conjunction with the health supervision visit.

• Encourage use and/or establishment of a medical home for continuity-based healthcare.

• Identify conditions that may be life-threatening or disabling, or those that may predispose to injury or illness related to participation in physical activity.

• Provide an opportunity for discussion of health and lifestyle issues.

Historically, the PPE has been performed on athletes, but many schools, school districts and state associations have expanded its use as a screening tool for students involved in other activities such as marching band and dance teams. For many otherwise healthy teenagers, this may be the only encounter with a healthcare provider that they have during adolescence. Ideally, the PPE is performed in the office of an individual’s primary care provider (PCP), allowing for better continuity of care instead of a mass group setting where hundreds of students are shuffled through multiple stations in a short period of time.

The student’s PCP has an established relationship, is likely to know the personal history, and usually has a complete set of medical records, including family history, immunizations and previous laboratory and imaging studies. Access to the complete medical record during the PPE reduces the possibility that a previously detected problem or family risk factor that would predispose the student to unnecessary risk will be missed or omitted.

The PCP may be less likely to overlook health issues inadvertently or consciously omitted on the PPE History Form. In addition, the PCP should have a better appreciation of the student’s known medical problems, a sense of the individual’s current health status, and knowledge of potential changes in treatment that would optimize participation.

For example, an asymptomatic student with a heart murmur and previous testing showing normal findings can be readily cleared for participation. If needed, the PCP can coordinate care with consultants or specialists and ensure proper follow-up for medical conditions considered a risk for sport/activity participation before determining medical eligibility.

The office setting typically offers privacy and a chance to discuss confidential issues. Familiarity also provides an opportunity to counsel a student on sensitive issues such as mental health, birth control and prevention of sexually transmitted infections in addition to a variety of risk-taking behaviors such as tobacco use, alcohol and recreational drug use, appearance and performance-enhancement drug and supplement use, and unsafe nutritional practices.

Teenagers are often more willing to discuss these issues with someone they know and trust, rather than a stranger in a group examination. Additionally, if the screening identifies any concerning risk-taking behaviors, the PCP can promptly connect the individual with appropriate resources.

For these reasons, it has long been recognized that performing the PPE in a group setting in the school does not meet these goals and should not be utilized. Similarly, examinations done in an urgent care or retail clinic lack access to an individual’s medical record and should also be considered unsuitable. Individuals often arrive at these examinations with forms either partially completed or not completed at all and without a parent, so the data and medical history are inadequate for the health-care provider’s assessment and decision-making.

There are several challenging legal, ethical and privacy issues related to PPE, which are made more complex because of inconsistent laws and variable institutional policies and procedures. The information obtained through the PPE process is covered by both the Health Insurance Portability and Accountability Act (HIPAA) and the Family Educational Rights and Privacy Act (FERPA) and affect how personal health information (PHI) can be shared.

HIPPA applies to health-care professionals. This law creates standards on the use and disclosure of PHI. FERPA, on the other hand, protects students’ privacy within educational settings. FERPA regulates student education records in schools (those schools receiving federal funds) and sets standards for who can access educational records without consent.

Because both deal with different aspects of privacy in different contexts, HIPAA and FERPA rules can be confusing especially where they differ. For example, a PPE conducted in a health-care setting, like a physician’s office, would be protected by HIPAA rules. This would protect the participant’s personal physical and mental health information from being shared without their consent. However, if the same PPE is performed in a school setting, such as a school-sponsored mass PPE screening event, or by a school employee, the records are considered educational in nature and subject to FERPA rules. This means school staff and other permitted individuals can access those records without specific consent.

Any contractual relationship that exists between health-care providers and their employing institution may also impact privacy protections. For instance, providers (e.g., athletic trainers, school nurses and school physicians) directly employed (or contracted) by the school are subject to FERPA. On the other hand, health-care providers contracted from medical practices or hospitals (such as athletic trainers in an outreach program) are still subject to HIPAA regulations.

Privacy of PHI remains important and just because an individual wants to participate in sports or other activities does not imply all protected health information can be freely shared with schools or institutions. The bottom line is the Medical History and Physical Exam portions of the PPE are considered PHI and should be handled by health-care professionals (e.g., athletic trainers and school nurses). The Medical Eligibility Form is the portion that can be maintained by school personnel for their recordkeeping purposes.

Reference:
Preparticipation Physical Examination, 5th Edition; David Bernhardt & William Roberts (Eds.) American Academy of Pediatrics Publishing Staff. ISBN: 978-1-6002-301-6. 2019