Computerized clinical reminders (CRs) can improve compliance with evidence-based practices in preventive care and chronic disease management. However, observational research is needed to explain the known variability in the use of CRs. We conducted ethnographic observations of nurses and providers using CRs in outpatient primary care clinics for two days in each of four geographically distributed Veterans Administration (VA) medical centers. We found that use of CRs was impeded by (1) lack of coordination between nurses and providers, (2) using the reminders while not with the patient, impairing data acquisition and/or implementation of recommended actions, (3) workload, (4) lack of CR flexibility, and (5) poor interface usability. We discuss implications of these findings for CR system design and provide recommendations for redesign to facilitate the effective use of CRs.