I think the point that version_five was trying to make is that the decision makers have no visibility on how usable a system is in advance - they only see the checkboxes. At best, decision makers if they're curious, will learn how unusable and inefficient the system is years after they're locked in to their multi-million dollar commitment to implementing and training people on the system. And upon this discovery the vendors are of course there to say, that the hospital just need some more customizations, user training, or a new expensive module. Which just furthers the hospital's lock-in. The lather-rinse-repeat of enterprise software.