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We examined what it takes to use an electronic medical record system effectively in a large acute care hospital. As our findings emerged, the value and complexity of consistency in use became salient. At our site, consistency in use had five interrelated dimensions (process, meaning, form, place, content) with multiple different consequences. From a theoretical perspective, our findings suggest the need for more research at the intersection of system design and user practices on how inconsistencies should be conceptualized, what causes them, and how they should be addressed. From a practical perspective, the insights help explain the difficulty of achieving effective use and provide insights for improving it.