This episode is part of a special series that focuses on organizations that received grant funding from the COPIC Medical Foundation for initiatives that address the issue of reducing fragmentation across care settings. Dr. Zacharias welcomes Dr. Matthew Gonzales and Dr. Deborah Unger who are affiliated with a grant provided to the Providence Portland Medical Foundation. Grant funding supported Providence and the Oregon Physician Orders for Life Sustaining Treatment (POLST) Registry for a partnership to build a bi-directional interface which integrates Providence's Epic electronic health record with the Registry. Dr. Gonzales and Dr. Unger discuss about how POLST is designed to respect people’s wishes around care/treatment inside and outside of health care settings. They also talk about how POLST is utilizing digital technology to inform others across different systems, the challenge of state-by-state legislation, and the insight gained through the project so far.