NextGen does a great job selling a product, but a very poor job of supporting their product and their clients. The upgrade process is as others have mentioned, a nightmare. Customization? Sure for $250 an hour. Or you can hire an independent contractor for about half the cost. However - then the upgrade process becomes even more of a nightmare. Very steep learning curve, too much content that cannot be separated by specialty, and a cardiology product that looks NOTHING like the rest of the application. I would not recommend this software.