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Large Or Small?

June 25, 2010
by Michael Restuccia, Vice President and CIO, Penn Medicine
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In the End, the Approaches Are Different, but the Goals Are the Same
Michael restuccia
Michael Restuccia

I have been fortunate to have served in leadership positions in both large and small healthcare information systems departments. The roles and responsibilities of the chief information officer are remarkably similar, whether in a community hospital or a large academic medical center. Yet differences do exist, particularly as a result of unique environmental factors which call for different approaches by the CIO. In what follows, I review just several of these factors and the impact they have on how CIOs lead their teams.


An obvious difference is the overall size of an organization and the complexities that result. On average, hospitals and medical centers spend three percent of their revenues on information systems. In a typical smaller institution with 2,000 employees, that translates into approximately $7 million in annual IS spending, while a larger institution with 16,000 employees may spend $75 million. Part of the difference is represented by the inevitably wider range of activities and unique departmental requirements associated with a larger institution. These may include more intensive patient care features as well as research capabilities and unique infrastructure and networking connectivity. Such differences frequently steer larger organizations away from a single-source approach and towards a best-of-breed solution. Thus, issues such as change control, integrated testing, interface development, and communication all take on higher degrees of complexity and require more dedicated resources to manage.


Large organizations are more diverse than smaller ones in a number of ways, ranging from the mission of the organization to the technologies supporting the mission. With more employees come more managers (and more diverse perspectives); all believing (perhaps rightly) that there is no more important position in the health system than theirs. Under such circumstances, opinions about, for example, being an early IS adopter or late follower vary greatly, and building consensus in such an environment becomes even more critical. Ongoing education and communication on the part of the IS team are critical to minimizing disruption and lost time on items that generate diverging opinions.


Smaller organizations tend to have clear and well-defined decision-making structures. Often, a few individuals make the mission-critical decisions that will lead to organizational success or failure. Alignment with those leaders is critical to a CIO's success. In larger healthcare organizations, decisions are typically made on a consensus basis. Once made, they tend to be governed by multidisciplinary teams that represent multiple service lines and departments within the health system. In such an environment, the CIO must often serve as an ambassador to each constituency by sharing information and obtaining feedback to address individual concerns. In this role, the CIO may become the “organizational glue” that helps tie the organization together and enable it to reach a decision that represents the interests of all.


Effective communication is, of course, important in any leadership role. How one communicates can vary depending upon the physical location of colleagues and the tools available. Smaller organizations are often characterized by the hub-and-spoke approach, with one-on-one discussions with members of the leadership team, and with results then being conveyed to the institution as a whole. Whether in the form of scheduled meetings or informal encounters in the hallway or lunch room, there is usually ample time to share and communicate the status of projects, plans, or other topics of interest. In addition, in smaller organizations, centralized leadership teams are usually primed for communicating a consistent message to be heard by all. Within larger health systems, informal meetings are more infrequent, and face-to-face meetings only take place if time is scheduled on the calendar, often weeks in advance. Coordination becomes a real challenge. In such cases, CIOs must be flexible and must adjust their schedules to meet the needs of their clients. At the same time, the sheer size of large organizations generally means that more frequent use of websites, newsletters, and other mass communication approaches are required to ensure that a consistent message is received by all.

While the needs and demands may indeed vary, the reality is that there are more similarities than differences between large and small organizations. - Michael Restuccia

Law of big numbers associated with not-so-positive events

With more employees usually come more frequent opportunities for potentially disruptive personal events. Whether it's an illness, accident, or a child's doctor appointment, the larger the organization, the more frequently managers have to respond to such events. With this higher frequency, it's easier to become frustrated. Therefore, it's vital as CIO to put yourself in the employee's shoes and make the extra effort to show your support and understanding while still making sure that the job gets done. Whether in a large or small organization, how a CIO (or any manager) responds to such situations often becomes part of the culture and can almost take on a predefined set of actions. Managers must therefore ensure consistency of response to similar events, all the while communicating in both word and deed to your team that you are supportive, concerned, and care for the personal well-being of the employee.


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Michael, I enjoyed reading your thoughts. I think your comments are spot-onlarge or small there is more work to be done than can be accounted for by prior experience, especially with all of the "help" coming from DC.

I think the focus on EHR often blurs some of the other opportunities the CIO may address. One of those is Patient Relationship Management (PRM). The other, a much more difficult sell is whatever a hospital might call a Practice Management System.

While I spend most of my time consulting on HIT to hospitals, the time I have spent with with clinics strongly suggests that the much greater need is on the practice management side. If there is merit in extrapolating the rework, ineffectiveness, and non value-added processes of a clinic to that of a hospitaland I believe there isthe potential ROI to be gained via IT by implementing sound business principles far exceeds the negative ROI of most EHR implementations.