The successful implementation of clinical information systems is difficult. In examining the reasons and potential solutions for this problem, the medical informatics community may benefit from the lessons of a rich body of software engineering and management literature about the failure of software projects. Based on previous studies, we present a conceptual framework for understanding the risk factors associated with large-scale projects. However, the vast majority of existing literature is based on large, enterprise-wide systems, and it unclear whether those results may be scaled down and applied to smaller projects such as departmental medical information systems. To examine this issue, we discuss the case study of a delayed electronic medical record implementation project in a small specialty practice at Columbia-Presbyterian Medical Center. While the factors contributing to the delay of this small project share some attributes with those found in larger organizations, there are important differences. The significance of these differences for groups implementing small medical information systems is discussed.