To mitigate rising healthcare costs and FFS (Fee for Service) charges, large healthcare organizations are beginning to restructure their models for providing patient services. Many of these healthcare organizations have implemented an Electronic Medical Record (EMR) to free the physical location of charts and automate business rules. This case study examines the failure of a large metropolitan department of public health's (DPH) attempts to upgrade their EMR system. While political, technological and economic barriers persist, the assumptions made by this proprietary EMR vendor did not reflect the diverse services provided by the organization. As a result, the implementation failed after two years of effort. Vendors of EMR systems need to provide flexibility with rules engines and user interface design to accommodate the changing landscape of healthcare as a service.

The hospital organization, containing a variety of clinical providers and supporting departments, is a complex service delivery system. This system requires a taxonomy of clinical documentation between the different clinicians and services for patient care coordination and billing justification. Our project, MD:Notes (where MD stands for "multiple device") is about the design of a new application for physicians to enter progress notes, one component of all clinical documentation. This paper focuses on the user-centered research conducted at Highland and San Francisco General Hospital around the physicians, the primary stakeholders of the application. Our research demonstrates that a lack of mobility, difficult entry, transcription lag time and a lack of mandate to switch completely over to the electronic format is causing breakdowns that lead to poor service quality. While the design of the application is focused around the physicians, considerations must also be made to the secondary stakeholders, who are concerned with cost, reports for auditing and interoperability. Addressing the goals of all those in the service chain will lead to an application with a higher level of potential adoption.