Early studies of health information system failures identified the central role of the human, social and organizational contexts in which information systems operate. They set the challenge for researchers to understand how to obtain the best fit between the technical systems (e.g. the information systems and associated work practices) and the social systems (e.g. organizational culture, social practices and behaviors, and political milieu), resulting in a socio-technical approach towards health information systems. It has been six years since the first conference and the quality of the research papers has continued to improve as have the theoretical sophistication and empirical methodologies. Considerable advances are evident, though many of the underlying challenges, such as our ability to design, implement and evaluate safe, useable and effective systems within complex healthcare organizations, remain.