BACKGROUND: The success of a facilitator-based model for advance care planning (ACP) in LaCrosse, Wisconsin, has inspired health systems to aim for widespread documentation of advance directives, but limited resources impair efforts to replicate this model. One promising strategy is the development of interactive, Internet-based tools that might increase access to individualized ACP at minimal cost. However, widespread adoption and implementation of Internet-based ACP efforts has yet to be described. OBJECTIVE: We describe our early experiences in building a systematic, population-based ACP initiative focused on health system-wide deployment of an Internet-based tool as an adjunct to a facilitator-based model. METHODS: With the sponsorship of our healthcare system's population health leadership, we engaged a diverse group of clinical stakeholders as champions to design an Internet-based ACP tool and facilitate local practice change. We describe how we simultaneously began to train clinicians in ACP conversations, engage patients and health system employees in thinking about ACP, redesign clinic workflows to accommodate ACP discussions, and integrate the Internet-based tool into the electronic medical record (EMR). RESULTS: Over 18 months, our project engaged two subspecialty clinics in a systematic ACP process and began work with a large primary care practice with a large Medicare Accountable Care Organization at-risk population. Overall, 807 people registered at the Internet site and 85% completed ACPs. CONCLUSION: We learned that changing culture and systems to promote ACP requires a comprehensive vision with simultaneous, interconnected strategies targeting patient education, clinician training, EMR documentation, and community awareness.

INTRODUCTION: Reports from patients and healthcare workers dealing with COVID-19 underscore experiences of isolation and fear. Some of this experience results from the distancing effect of masks, gloves, and gowns known as Personal Protective Equipment (PPE). One approach to bridging the divide created by PPE is the use of PPE Portraits, postcard-sized pictures affixed to PPE. OBJECTIVE: Our confidential, email-based survey aimed to quantify provider attitudes towards PPE Portraits. METHODS: PPE Portraits were piloted at an academic, safety-net health system experiencing a COVID-19 patient surge in April-May 2020, necessitating use of full PPE for COVID-positive patients and surgical masks in all hospital settings. Our survey assessed staff exposure to PPE Portraits, attitudes towards PPE Portraits, and potential program expansion. For staff wearing PPE Portraits, we also assessed perceptions of interactions with other staff and patients/families and impact on personal wellbeing. The University of Massachusetts Medical School's IRB designated this a quality improvement project (#H00020279). RESULTS: Over half of survey respondents (n=111/173, 64%) reported exposure to PPE Portraits. Attitudes towards PPE Portraits were positive overall, with agreement that PPE Portraits were a good idea (89%), improved provider mood (79%), enhanced perception of team connection (72%) and more positive among those who reported exposure. Open-ended responses (n=41) reinforced positive survey data, and also raised concerns about infection control (n=6), cost/logistics (n=5), and provider vulnerability (n=3). CONCLUSIONS: Providers report that PPE Portraits may represent a positive, patient-centered idea that helps reassure patients, is well-received by interdisciplinary staff, and may enhance patient and team interactions. Potential adaptations to address concerns include "photo pins," and donor/ patient and family experience department support for costs. KEY MESSAGE: This article describes a cross-sectional study that investigated provider perceptions on the use of PPE Portraits, an intervention that addresses the barrier to patient-provider connection presented by the use of PPE. The results suggest that implementation of the PPE Portrait Project is feasible, acceptable, and effective.