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Medical professionals in various specialties work closely with digital images for diagnosis, research and education. Electronic applications of image management are emerging in virtually every medical specialty, including cardiology, radiology, pathology, dermatology, orthopedics, OB/GYN etc. Compared to radiology, there is a less well-established adoption of such applications as PACS in dermatology in daily practices. Mizzou Dermatology Image Database (MDID) is a web-based medical image management system dedicated to the daily practice at Department of Dermatology, University of Missouri. A longitudinal system user behavior and acceptance study has been conducted using mixed methodologies including periodic surveys, field observations, interviews and application usage analysis. The discoveries from this study is expected to shed some lights on understanding the roadblocks and best practices when designing and introducing health IT applications for a successful improvement in quality and efficiency.