Robert Slepin has a very interesting job, as emeritus CIO advisor at electronic health record giant Epic. There are only a dozen or so of these contractors, who are available on demand to Epic provider clients that need strategic advice or interim executive assistance from someone who's deeply experienced with planning, implementing and maintaining Epic EHR system.

Slepin – who has served as chief information officer or in other top IT roles at health systems such as Johns Hopkins Medicine International, Sutter Health, John C. Lincoln Health Network in Arizona, University Health Network in Toronto and AxisPoint Health in Colorado – enjoys helping other healthcare leaders manage the challenges of EHR operation and optimization.

We spoke with him for his perspective on the world of Epic and its technology – discussing the kinds of hurdles hospitals and health systems call him in to advise, how he works with teams onsite at a provider organizations, his methodology for problem-solving and troubleshooting and more.

Q. You're in a unique position with the biggest EHR player on the block. You also have long experience as a healthcare CIO. What are common challenges that other CIOs and IT leaders at hospitals and health systems call you in for?

A. CIOs and health system leaders call me in to be a strategic advisor, and sometimes also as a project director, for clinical transformation, electronic health record and other large-scale or innovative IT projects that improve the patient experience and outcomes, clinician wellbeing, cost efficiency, and health equity.

Common challenges exist at each stage of the project life cycle, from assessing feasibility to positioning a project for board approval to successfully implementing a project to realizing benefits longer term.

My services include help with building a business case; assessing readiness and risks; determining project scope, approach, phasing, schedule and budget; designing the governance and project structure and process; advising key stakeholders on project status, risks and opportunities; project planning; staffing the team; managing the human side of change; directing the project; transitioning the project to operations; and advising, coaching and mentoring CIOs and IT directors on EHR optimization, digital strategy, portfolio roadmaps and operations.

Risk management is a common challenge. In all aspects of planning, implementing and operating EHRs and other enterprise systems, it is essential to identify, evaluate and mitigate risks to ensure the responsible use of resources and delivery of value. While there are numerous potential risks to watch out for in an EHR project, the highest priority always is mitigating risk to patient safety.

Because transitioning from one system to another in a clinical setting is inherently high-risk, it is of the utmost importance to keep eyes wide open and ensure every patient remains safe when systems are designed, built and transitioned into production. CIOs and health system leaders seek my advice and support at each stage of a project to help them in identifying, evaluating and mitigating patient safety and other risks.

Cost is another common challenge. EHR and other projects require a significant capital investment and often an increase in operating expenditure to sustain the system over the longer term. CIOs are challenged to develop business cases that are credible and affordable from both the capital and operating spend perspectives.

The total cost of ownership of the system is typically forecast over a ten-year period, and benchmarks with peer hospitals are used to inform budget-setting and assess reasonableness. While boards, CEOs and CFOs usually want to see some amount of hard-dollar return on investment, the purpose of EHR projects is not to save money but rather to save lives, improve patient care and help people optimize their health.

I support budget development and cost optimization by assisting with high-level and line-item cost estimation and benchmarking and by providing an independent, objective perspective informed by experience at numerous other sites.

Benefits identification and realization is another typical challenge. There is a growing body of evidence from numerous EHR and clinical information system implementations across the world over the past few decades. The available evidence is a starting point for identifying benefits that may apply to the context of any given organization. Business cases usually include not only costs and risks but also financial, clinical and other benefits to be achieved as a result of the project.

While it is easy to find public evidence of others' outcomes, it can be hard to translate the information to one's local context since every organization is unique and has a different baseline.

It is even more difficult to get buy-in from clinical, operations and medical executives to commit to meeting specific targets, for example, taking costs out of their operating budgets from increased efficiencies, given the complexity, uncertainty, volatility and ambiguity of a large, complex EHR implementation; lapse of time between starting a project, going live and realizing benefits; and internal political risks and external environmental uncertainties.

To meet the challenge of strengthening benefits planning, CIOs have sought my assistance with benchmarking with other sites; identifying opportunities to translate benefit concepts to their organizations; engaging with key stakeholders to seek sponsorship and participation in benefits planning; aligning benefits plans with the EHR implementation plan; and designing and assisting with the transition of the benefits plan into an operational governance structure and process post-live.

Q. How exactly do you go about working with the team onsite at the provider organization? What is your role? Who do you interact with?

A. My approach in working with the onsite team at the provider organization depends on the role I am playing. I might be serving as a board advisor, executive advisor or project director – or a blend of these roles in some cases. It also depends on other factors, for example, the specific problem the organization needs to solve, and the objectives, scope and schedule for the engagement.

Leadership preferences and organizational culture can also influence how my role is defined and whom I interact with. When my engagement is with a provider organization under the umbrella of Epic's Emeritus program, which is my preference because it is so easy for providers to engage me in this way using their existing agreement, I coordinate closely with Epic's senior leaders responsible for the implementation at the site.

When I am engaged as a board advisor, the first thing I do typically is to meet with the CEO to discuss the requirements for the engagement, ensure clarity and alignment and write-up a formal letter that both of us sign. The letter specifies the objectives, deliverables, approach, schedule, working relationships, status reporting, compensation and other elements.

Before or after finalizing the letter with the CEO, I would meet with the board of directors or board committee chair and the CEO together to review, discuss and ensure alignment.

I would also be introduced to the other key stakeholders, for example, the CIO, CFO and CMO, and kick off the engagement at the executive level, followed by participation in various organizational meetings, document review and one-on-one interviews with executives, business sponsors, project directors, IT directors and other key individuals identified by the CEO as being appropriate to meet with.

Over the course of approximately 30 days, I would draft and revise an initial report of observations and recommendations, review the draft with selected key stakeholders to receive their input and ultimately deliver a final written report and oral presentations to management and the board. Depending on the engagement, my advisory services could continue into a subsequent phase of the project – and last as long as several months to a year post-go-live of the new EHR.

As an executive advisor, my approach is similar to the board advisor role, but there would be less if any interaction at the board level. I advise and coach CXOs in all aspects of clinical transformation, social and technical, at all phases of the program life cycle.

What this looks like includes one-on-one or small group meetings and sometimes occurs during a meal together, which is an opportunity to get away from the office, be in a more comfortable, relaxed setting, and go deeper into areas of interest.

In any advisory role, I work closely with colleagues at Epic (and other IT vendors depending on the project) to get their perspectives, consult with them on their and my ideas for action, and keep them informed. Leaders at Epic I typically work with include VPs, implementation executives, implementation directors, technical coordinators and customer happiness executives.

They bring valuable information, insights and recommendations, which I carefully consider and integrate into my assessment and recommendations.

As a contract project director leading an EHR implementation, my job is to complete any remaining pre-implementation planning, finalize the budget, fully staff and train the project team, operationalize governance and project management office controls, execute all aspects of the project, safely go live on time and within budget, stabilize the new system, and transition the system to the operations team.

In this role, I work with the same stakeholders as I would as an advisor – plus many more roles and people across the hospital or health system, for example, most departments within IT; medical staff, clinical and corporate leadership; providers, nurses and health professionals; safety, quality, risk, legal and compliance; and finance, human resources, communications, facilities, purchasing and other corporate functions.

As a project director, I am joined at the hip with Epic's implementation director and work closely also with Epic's implementation executive – as well as peer IT leaders and other sponsors across the healthcare organization.

The critical need for excellence in partnering, communication, coordinating and aligning with Epic and health system leaders cannot be understated. These projects are a huge lift and it takes a village of people working together very, very well to get the job done in an optimal way.

Q. In this role, you obviously are what could be called a problem solver. What is your methodology for going about solving problems with EHRs?

A. Problem solving is a critical process during an EHR project – but it's best, of course, to prevent problems in the first place. Problem prevention requires following best practices and adopting sound guiding principles such as putting patients first in all decisions and actions; co-creating a transformation with clinical leadership, enabled by IT and Epic; and building quality into the EHR design, implementation and operations.

Problems inevitably occur, of course, and my approach to solving problems is my own recipe and multi-framework. It is a blend of Epic's proven EHR implementation methodology with acclaimed frameworks for problem-solving, leading organizational change, governing IT, managing programs and projects, developing and delivering software, caring safely, operating IT, and continuously learning and improving.

To achieve program objectives and transformational outcomes, build in quality and solve problems when they occur, my approach includes the following aspects:

• Always put patients first

• Respect everyone

• Instill a clear, inspiring vision and actionable mission

• Create a culture of safety, candor, curiosity and learning

• Iteratively plan, execute, check and adjust

• Engage stakeholders

• Implement good governance

• Recruit and develop exceptional talent

• Integrate human and technical aspects of change

• Adapt best and leading practices

• Apply a scientific approach to continuous improvement

• Leverage frameworks such as Lean, Agile, Cynefin, Toyota Kata, Project Management Body of Knowledge, IT Infrastructure Library, COBIT and others

• Learn with the global community of Epic users

• Partner with Epic and other vendors

When problems arise, it is important for work to be visible, for changes (which sometimes contribute to problems) to be documented and apparent, for people to feel safe in speaking up, and for leaders to be visible, accessible, respectful and supportive. These conditions enable everyone to see problems for what they are, draw attention to problems and work together to solve them.

My favorite way to solve problems is not solving them myself. I prefer to coach and support other team members in problem-solving, whether on their own or in smaller groups with colleagues. It would of course be easier in some cases for me to take command, figure it out and solve the problem. And sometimes I do need to own the problem.

But I view my role on projects being as much about building people's skills and abilities as about building systems, infrastructure, devices, software, data, interfaces, reports and workflows. For people to learn to be better problem-solvers, they need experience, methods/tools and coaching.

One of my greatest sources of satisfaction in a project engagement is the opportunity to serve as a role model and coach for the team, especially the next generation of leaders in hospitals and healthcare organizations.

When I engage or lead others in problem-solving, I use numerous problem-solving techniques and teach and coach others in using these methods. None is my own invention. I have studied, practiced and applied ways of solving problems (and improving processes).

There are tools from high-reliability organizations that many hospitals have on hand, and I like to adopt or adapt these local methods and tools because they are familiar, accessible and easily repurposable for the project. Epic also has excellent problem-solving approaches based on extensive experience implementing and operating their software, which can be leveraged.

SBAR (Situation-Background-Assessment-Recommendation) is a template I frequently use for problems that are simple or complicated, but not too complex.

I also use techniques from the worlds of Toyota, Lean, Systems Thinking and Complexity Science, such as Toyota's Practical Problem Solving and A4 methodologies, 5 Whys Analysis, Root Cause Analysis, Theory of Constraints evaporating cloud technique, Toyota Kata and more.

The Cynefin framework helps me figure out what domain the problem exists in: chaotic, complex, complicated or clear. Depending on the domain, I might choose different techniques.

Q. Please talk about one example from your body of work at Epic. What was the challenge? How did you solve it? What were the outcomes?

A. One example is from 2019-2020, when I was honored to play several roles on Alberta Health Services' (AHS) Connect Care clinical information system (CIS) project, a more than $1 billion, multiyear program that included the rollout of Epic.

I advised the board, CEO and executive sponsors, and I served as a project director for the implementation work-stream, partnering with the clinical program officer and working closely with the CIO, CMIO, PMO, applications executive, Epic leaders, AHS clinical leaders and many team members.

One challenge during this engagement, which was under the auspices of the Epic Emeritus program, was providing the board with my view of the project's overall status and risk posture and giving the board members clear, concise, relevant information to help them fulfill their fiduciary responsibilities for oversight and to increase their sense of comfort and confidence in the direction of the project, considering the many risks inherent in such a large, complex endeavor.

I met this challenge in much the same way I described earlier in how I operate as a board advisor. The board received an independent, objective, expert perspective on the project – and the outcomes included additional information, which the board found valuable and enabling them to feel a higher level of comfort with the information and their understanding of the project's direction.

Another challenge was advising management on risks, reviewing mitigation actions and providing recommendations to ensure readiness for deploying Epic across the Edmonton Zone in the first of nine waves, with an initial go-live in November 2019.

As is typical of these projects, objectives included staying on schedule, sticking to the budget, and meeting scope and quality requirements with the highest priority on patient safety through the transition. Through ongoing risk identification, evaluation, monitoring and discussions, I contributed to the Connect Care PMO's risk management program.

One of the outcomes was a positive report from the Alberta provincial auditor, with no recommendations for improvement. Most important, the transition to Epic occurred with eyes wide open and a focus on patient safety, helping keep patients safe through the transition.

My other responsibility was codirecting the implementation work stream, which included data abstraction, protocol conversion, appointment and case conversion, cutover and command center. In this role, I regularly reported to the engagement, adoption and implementation committee and participated in the overall project steering committee, PMO and other groups.

This work stream was accountable to create and implement an overall implementation strategy to drive consistency and alignment across all waves; develop a structured implementation framework to support and guide zone and local ability to execute implementation tasks; provide support and direction to sponsors and key stakeholders to ensure effective and aligned implementation activities; ensure alignment with organization change management, communication, technical, CMIO and other strategies; remove barriers; escalate issues; support execution; and drive continuous improvement.

AHS's Wave One was a success. According to Alberta's Auditor General's review of the initial Epic launch in November 2019 in a published report, "AHS experienced a few technical issues, some service delays, and some initial frustrations immediately following the launch. However, overall AHS felt the launch and immediate sustainment of Wave One was a success and, most importantly, was safe for patients undergoing care at that time."

The successful outcomes from Wave One were not because of me; it was a huge team sport. I did my small part to help. There were thousands of AHS team members involved in the design of the system and numerous people focused on Wave One. Working together, the team developed and implemented the processes, controls and plans for executing the work and managing the risks to enable an on-time launch of the first wave of Connect Care safely and effectively.

According to the auditor's report, one of the key success drivers was that "the program was not led or managed as an 'IT project.' Representatives of operations, clinical staff and physicians and AHS IT co-led the program. The involvement of operational and clinical staff in the program was pervasive."

Clinical, operations and medical leadership and co-creation of a program like Connect Care is a critical success factor and worth calling out. This co-leadership model was so important to AHS's results and also is commonly seen as a key enabler of other hospitals' and healthcare organizations' clinical transformation projects.

Co-designing the change, participation, active, visible presence of leaders from clinical, operations and IT – this kind of approach to leading change is vital.

AHS' board, senior executives, CIO, CMIO, clinical program officer, and many other leaders and team members – they were amazing in their extraordinary commitment, talent, teamwork and execution. While I joined the team for a relatively short period of time during their multiyear journey and can comment only on the outcomes I saw when I was there, the true value and return from these kinds of investments is seen after the project is done, which is when the clinical transformation actually starts.

The EHR implementation plants the seeds in the soil; go-live and transition to operations adds water and sunlight; adoption of the new system and optimization of its capabilities happens during ongoing operations, as people learn and adjust to the new system, do things in new and better ways, and are constantly improving and innovating – this is where value is created for patients and those who care for them.

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