This paper argues that we should understand the process of IT design as the development of sociotechnical configurations. Drawing upon our experiences with an electronic patient record (EPR) on an Intensive Care Unit (ICU), we depict medical work practices as natural systems. Several considerations for design are developed. First, the EPR should not be overly structured with rationalistic and prefixed notions of the organization and content of medical work. Implementing structure is crucial, however, this should be derived from detailed, empirical knowledge of the practice involved. Second, it is crucial to ensure that the usage of the system will yield immediate benefits for primary users: the systems should support work, not generate it. Third, designing IT should include being aware of the socio political nature of seemingly 'neutral' tools as EPRs.