Approaches to the development of information systems in large health care institutions range from prototyping to conventional development of large scale production systems. This paper discusses the development of the SignOut System at Mount Sinai Medical Center, which was designed in 1997 to capture vital resident information. Local need quickly outstripped proposed delays for building a production system and a prototype system quickly became a production system. By the end of 2002 the New SignOut System was built to create an integrated application that was a true production system. In this paper we discuss the design and implementation issues in moving from a prototype to a production system. The production system had a number of advantages, including increased organizational visibility, integration into enterprise resource planning and full time staff for support. However, the prototype allowed for more rapid design and subsequent changes, less training, and equal to or superior help desk support. It is argued that healthcare IT systems may need characteristics of both prototype and production system development to rapidly meet the changing and different needs of healthcare user populations.