CNAs, skilled nursing staff, hospice aides, home health teams, and other frontline caregivers already navigate incredibly difficult environments while supporting patients and families through some of the most challenging moments in healthcare. Missing advance directives or other advance care planning (ACP) information should not add to that burden. As we recognize National Nursing Assistants Week, it’s a reminder that improving ACP accessibility is not just about compliance or technology. It’s also about helping ensure frontline caregivers have timely access to the information they need to help honor patient wishes across the continuum of care. #NationalNursingAssistantsWeek #AdvanceCarePlanning #CareCoordination #HealthcareIT #PatientCare #MyDirectives

Healthcare is incredibly fluid. Patients move across emergency departments, hospitals, rehabilitation facilities, skilled nursing, home health, hospice, physician offices, EMS encounters, and long-term care settings — sometimes repeatedly within short periods of time. But too often, advance directives, portable medical orders, and other ACP documents do not move with them. When preferences and treatment decisions are fragmented across paper files, disconnected systems, portals, fax machines, and isolated workflows, clinicians, caregivers, patients, and families are often left making critical decisions without the information they need. Advance care planning is not just about document creation. It is also about accessibility, interoperability, workflow integration, and ensuring patient preferences remain available throughout the continuum of care. #AdvanceCarePlanning #Interoperability #HealthcareIT #DigitalHealth #CareCoordination #HIE #MyDirectives

Healthcare is incredibly fluid. Patients move across emergency departments, hospitals, rehabilitation facilities, skilled nursing, home health, hospice, physician offices, EMS encounters, and long-term care settings — sometimes repeatedly within short periods of time. But too often, advance directives, portable medical orders, and other ACP documents do not move with them. When preferences and treatment decisions are fragmented across paper files, disconnected systems, portals, fax machines, and isolated workflows, clinicians, caregivers, patients, and families are often left making critical decisions without the information they need. Advance care planning is not just about document creation. It is also about accessibility, interoperability, workflow integration, and ensuring patient preferences remain available throughout the continuum of care. #AdvanceCarePlanning #Interoperability #HealthcareIT #DigitalHealth #CareCoordination #HIE #MyDirectives

Advance care planning cannot succeed as a disconnected workflow. If ACP requires clinicians to leave the EHR, search for documents manually, rely on faxed forms, or navigate fragmented systems, adoption will always struggle, regardless of how important the conversations may be. For ACP to scale meaningfully across healthcare, it must become part of normal clinical workflows. Accessible. Integrated. Actionable. The future of advance care planning depends not only on encouraging conversations, but on reducing the operational friction surrounding them. #AdvanceCarePlanning #HealthcareInteroperability #HealthIT #ClinicalWorkflow #DigitalHealth

A simple question: If a patient has already completed an advance directive, designated a healthcare agent, and discussed their wishes with family... ...but none of that information is available when a critical healthcare decision must be made, has the healthcare system truly benefited from that planning? Accessibility is not a convenience. It's a requirement. #AdvanceCarePlanning #PatientCenteredCare #HealthcareInteroperability

During EMS Week, it’s worth recognizing that EMS professionals make critical decisions in minutes, often before a patient reaches the hospital. Portable medical orders like POLST forms and DNRs only work if they are accessible in the field. Too often, EMS teams still face fragmented workflows, paper documents, faxed forms, and disconnected systems that make patient goals and medical orders difficult to access when time matters most. Advance care planning infrastructure has to extend beyond the hospital, beyond the EHR, and into the moments when critical decisions are actually being made. Because ACP isn’t just documentation. ACP is infrastructure. Real-time healthcare requires real-time access to patient intent. #EMSWeek #AdvanceCarePlanning #Interoperability #HealthIT #DigitalHealth

Healthcare is rapidly moving toward real-time, connected workflows. APIs, interoperability, and embedded EHR experiences are changing how healthcare organizations exchange information and coordinate care. Advance care planning infrastructure needs to evolve with the rest of healthcare. Too many advance directives and portable medical orders still exist in fragmented workflows, trapped in scanned PDFs, faxed documents, disconnected systems, and processes that make critical information difficult to access when decisions need to be made quickly. ACP doesn’t fail when it’s created. It fails when patient goals, preferences, and medical orders aren’t accessible at the point of care. Real-time healthcare requires real-time access to patient intent. #AdvanceCarePlanning #Interoperability #HealthIT #DigitalHealth #PatientCenteredCare

For years, EMS has been told to look for a POLST form on the refrigerator. Think about that. In the moments that matter most—when a patient can’t speak, when seconds count—we’ve relied on a paper search to guide critical decisions. That’s not a reliable system. It’s a workaround. EMS clinicians don’t need better instructions on where to look. They need immediate access to clear, actionable medical orders at the point of care. When POLST forms, DNR orders, and other portable medical orders are available directly within ePCR systems, everything changes. EMS can see the information they need in real time, act with confidence, and deliver care that reflects the patient’s wishes without delay. This isn’t about replacing POLST. It’s about making it function the way it was intended—accessible, actionable, and present when it matters most. Because in emergency care, not finding the document isn’t a minor gap. It’s a system failure. #POLST #EMS #AdvanceCarePlanning #Interoperability #HealthIT #PatientCenteredCare

Today is National Healthcare Decisions Day. We’ve made real progress in advance care planning. More conversations are happening. More documents are being completed. But completion isn’t the finish line. If those preferences aren’t accessible when decisions are being made, they don’t guide care. That’s the gap. Create the plan. Make it accessible. #NHDD #AdvanceCarePlanning

National Healthcare Decisions Day is this week. You’ll see a lot of focus on encouraging people to complete advance directives. That matters. But completion alone doesn’t ensure those preferences will guide care. Not during transitions. Not in the ED. Not in the field. If advance care planning is going to deliver on its promise, those documents have to be accessible when and where care decisions are being made. That’s the gap that still exists. It’s the one worth focusing on. #AdvanceCarePlanning #HealthIT #Interoperability #NHDD

Advance care planning has made real progress. More conversations are happening. More documents are being completed. But there’s still a gap. When care decisions are being made—during care transitions, in the ED, in the field— those goals of care and treatment preferences aren’t always available. So even when the work has been done, it may not guide care. As National Healthcare Decisions Day approaches, the question isn’t just whether plans are created. It’s whether they can actually be used. That’s the gap that needs to be closed. #AdvanceCarePlanning #HealthIT #Interoperability #PatientCenteredCare #NHDD #POLST

Healthcare has made real progress documenting what matters most to patients. But documentation alone isn’t enough. The 4Ms Framework has helped align care around “What Matters.” Yet in many cases, those preferences are not available when decisions are actually being made. During emergencies. During transitions of care. In the field with EMS and emergency care teams. And when that information isn’t accessible, it doesn’t guide care. That’s where good intentions fail. As healthcare moves toward greater accountability for outcomes and patient-centered care, the ability to access and apply what matters most—at the point of care—won’t be optional. Organizations that solve this will be positioned for what’s next. Those that don’t will continue to document preferences that never influence decisions. We break this down in our latest blog: mydirectives.com/blog/what-m… #AdvanceCarePlanning #Interoperability #HealthIT #CareTransitions #PatientCenteredCare

A theme we’re hearing across #HIMSS26 this week is “data exchange at the speed of trust.” That principle is critical when healthcare data moves across EHR systems and care settings. We’re proud to share that MyDirectives has renewed our HITRUST R2 Certification for 2026, continuing our HITRUST-certified cybersecurity program in place since 2019. MyDirectives operates the only nationwide advance care planning document registry that is HITRUST certified, supporting secure interoperability across healthcare systems and care settings. That level of trust is especially important as states build ACP ecosystem initiatives on shared infrastructure and EHR platforms embed ACP directly into clinical workflows. We’re discussing this all week at #HIMSS26 inside the MEDITECH Booth in the Interoperability Smart Experience Pavilion. #HITRUST #Cybersecurity #Interoperability #HealthIT #AdvanceCarePlanning #MEDITECH

We’re onsite this week at #HIMSS26 in Las Vegas. Too often, advance care planning (ACP) documents exist — but they’re not accessible when and where care decisions are being made. They may be sitting in a file cabinet or safe-deposit box at home, scanned as a PDF in the patient chart, stored in a siloed document repository, or locked inside a single EHR that can’t be accessed across care settings. When preferences aren’t visible at the point of care, they’re difficult for clinicians and families to honor. That’s why digital ACP infrastructure must be directly integrated into the EHR — embedded within the clinical workflows clinicians already use to document, review, and make care decisions. When ACP is integrated into the EHR environment, patient preferences can be accessed whenever and wherever care is delivered — across emergency departments, hospitals, post-acute and community settings, and by EMS and emergency care teams in the field, including community paramedicine. This is what allows EHR platforms, health systems, and statewide ACP ecosystem initiatives to build modern ACP infrastructure on a nationwide registry. Clinicians can then access patient preferences directly inside the EHR environments they already use. At #HIMSS26, we’re demonstrating this approach inside the MEDITECH Booth in the Interoperability Smart Experience Pavilion at the Venetian Convention & Expo Center. Our team onsite includes: Scott Brown – President & CEO Michael Munoz – Chief Product Officer Maria D. Moen – Strategic Advisor If you’re attending HIMSS, and working on EHR integration, interoperability strategy, or ACP infrastructure, let’s connect. 👉 Schedule time here mydirectives.com/himss26 #AdvanceCarePlanning #Interoperability #EHRIntegration #HIMSS26 #MEDITECH

Here's the conversation we’re bringing to #HIMSS26 next week. Advance care planning (ACP) is often treated like a document problem, but the real challenge is workflow. If ACP lives in a separate portal, a static document repository, or a disconnected registry, clinicians won’t see it when decisions are being made. And when preferences aren’t visible, care defaults to escalation. That’s why ACP infrastructure has to be embedded directly inside the EHR. When ACP is integrated natively within clinical workflows, documented preferences can be accessed whenever and wherever care is delivered — from EMS and ePCR systems to emergency departments, hospitals, and post-acute settings. When ACP operates this way, statewide ecosystems become possible. States can build infrastructure on a nationwide registry, while clinicians access ACP information directly inside the EHR environments they already use. We’ll be demonstrating this approach next week inside the MEDITECH Booth in the Interoperability Smart Experience Pavilion at #HIMSS26. Our team onsite will include: Scott Brown – President & CEO Mike Munoz – Chief Product Officer Jessica Zan – VP, Clinical Implementations & Success Maria D. Moen – Strategic Advisor If you’re working on EHR integration, interoperability strategy, or statewide ACP infrastructure, let’s connect while we’re there. 👉 Schedule a meeting at mydirectives.com/himss26 #AdvanceCarePlanning #Interoperability #EHRIntegration #HIMSS26 #MEDITECH

The most consequential care decisions typically don't happen during scheduled healthcare visits. They happen when seconds matter and patient preferences must already be visible. Those moments occur in emergency departments and with EMS and emergency care teams delivering care in the field, including community paramedicine programs. They happen across transitions of care from home to ambulance, from ambulance to the ED, and from hospital to post-acute settings. Advance care planning (ACP) documents aren't just helpful. They're critical during emergency response and care transitions. When portable medical orders, like POLST and DNRs, and documented treatment preferences and goals of care aren't visible across those transitions, care can default to escalation. As accountability expands across settings and over time, the direction from the Centers for Medicare & Medicaid Services makes it clear that infrastructure must support visibility beyond a single encounter. Embedding digital ACP across hospital EHR environments like Epic, Oracle Health, MEDITECH, and PointClickCare, and integrating with EMS ePCR systems, ensures patient preferences follow the individual instead of remaining confined to a single facility. Don't wait for a care transition to expose the gap. See how digital ACP works across EHR and EMS workflows: mydirectives.com/schedule-de… #EMS #EmergencyCare #CommunityParamedicine #TransitionsOfCare #EHR #Interoperability #PatientGoals #ValueBasedCare #AdvanceCarePlanning

Rural healthcare systems are modernizing. Connectivity is expanding, and care coordination models are evolving. Yet in many states, advance care planning still does not function as interoperable infrastructure. Patient goals and portable medical orders often remain siloed within local systems or paper workflows, limiting accessibility during transitions of care. That's the structural gap. Regional Healthcare Transformation Program (RHTP) funding represents a golden opportunity to close it. When ACP is documented, structured, and accessible across EMS, community paramedicine, hospitals, and home-based care, coordination efforts align more closely with documented patient goals and medical orders. RHTP funds are finite. The opportunity to modernize ACP infrastructure is here right now. Read more in our latest blog by MyDirectives President & CEO Scott Brown: mydirectives.com/blog/rhtp-f… #RHTP #AdvanceCarePlanning #RuralHealth #HealthInfrastructure #ValueBasedCare

Advance care planning is no longer just about honoring care preferences. In value-based models, it directly affects utilization, episode costs, and downstream performance. In models such as BPCI Advanced and ACO REACH successors, alignment with patient goals influences length of stay, avoidable utilization, post-acute intensity, and readmissions. That impact is financially material. CMS is elevating ACP because accountability now spans settings. Care transitions, utilization, and outcomes are measurable. Accountability is no longer siloed within a single organization or platform. The exposure is clear. Treating ACP as a local program or a single-system feature is no longer sufficient. The infrastructure layer determines whether alignment actually changes performance. Embedding structured ACP across platforms like Epic, Oracle Health, MEDITECH, and PointClickCare — and making it interoperable across care settings — is not a feature decision. It is infrastructure readiness. If ACP is not embedded inside the clinical record and available at the moment patients or residents are being treated, organizations are structurally exposed to the accountability CMS is signaling. See how structured ACP functions across and inside EHRs: mydirectives.com/schedule-de… #ClinicalQuality #ValueBasedCare #Interoperability #ACO #BPCIAdvanced

MyDirectives will be in Washington, DC this week for the Assistant Secretary for Technology Policy (ASTP) 2026 Annual Meeting, with Scott Brown, President & CEO, and Senior Advisors Maria D. Moen and Lisa Nelson. We’re looking forward to engaging with peers and federal leaders to learn more about how ASTP is supporting CMS’ broader goal of treating advance care planning (ACP) as critical healthcare infrastructure. This means more than documentation. It means reliable, interoperable information that is available across care settings and at the moment decisions are made. When patient preferences aren’t accessible during emergencies, serious illness, or care transitions, decisions default to the system rather than the person. Building durable, standards-based, interoperable ACP infrastructure is how patient-centered care becomes operational, not aspirational. Looking forward to the conversations ahead. #AdvanceCarePlanning #PatientCenteredCare #HealthIT #Interoperability #CMS #ASTP #DigitalHealth #HealthcareInnovation #Standards #CareTransitions

Advance care planning is not a document problem. It’s an availability problem at the moment care decisions are made. CMS is making it clear that ACP information must be available across care settings, not trapped in a single system. Care doesn’t happen in one setting, and ACP can’t live in one system. As patients move across hospitals, skilled nursing facilities, home health, and emergency care, their wishes have to move with them, reliably and without friction. When they don’t, gaps appear precisely at transitions of care, where risk, cost, and clinical consequences are highest. That reality creates different pressures across the ecosystem: → States need a true ACP ecosystem, not a collection of disconnected programs that will have to be unwound later. → EHRs need a foundational, embedded ACP capability, or risk someone else becoming the standard inside clinical workflows. → Health systems need both, because they are ultimately accountable when patient wishes aren’t available at the moment decisions are made. This is no longer aspirational. It’s quickly becoming table stakes for value-based care and care transitions. 👉 See what this looks like in practice: mydirectives.com/schedule-de… #CareTransitions #ContinuumOfCare #ValueBasedCare #CMSQuality