This paper describes a number of important issues. In looking at various hospital and office based systems I found that there are a lot of features that could be improved but I keep hearing from the vendors that the users are not asking for some important things. Ask just about any physician if he or she wants to use a controlled medical vocabulary and would not know what you are talking about. When talking about terminology there are complaints about difficulties in using ICD and the preference for as few codes as possible or the preference for using free text. The the developers build their products based on these requests. Of course the physicians have misdiagnosed the problem which is the EMR diagnosis search interface and the inappropriate use of ICD for entering clinical concepts at the point of care. This would be solve by the use of an appropriate clinical terminology and well designed search methods that have been known for over 20 years. There is nothing that comes close to offering what SNOMED has and it is frustrating to be hobbled by being forced to use ICD while seeing SNOMED sitting on the sidelines because of a lack of demand.