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Factors affecting progress of the National e-Health Strategy in the NHS in England: A Socio-technical Evaluation.Background: This is a formative socio-technical study of the “middle out” NHS e-health strategy in England. It began in 2015 with an objective to become “paperless at the point of care by 2020”, focussing nationally on the “electronic glue”, (interoperability), to facilitate the inter-organisational exchange digital communications of patient data and leaving the choice of EHRs to local organisations. No academic research has been published into the strategy and similar studies rarely include sample groups of suppliers or IT consultants. So this study seeks to fill both gaps in knowledge. Such strategies are prevalent across westernised developed countries and can consume large sums of government funding and local resources. In consequence, their failure can be very costly. This study seeks to mitigate that risk whilst recognising that, as they operate in highly complex environments, choosing any particular type of “bottom up”, “middle out” or “top down” strategy construct does not guarantee success. Their outcome is dependent upon the successful navigation through a mix of factors, known and unknown, across technical, human and social, organisational, macro-environmental and wider socio-political dimensions through time. Findings: The “middle out” strategy is broadly more appropriate, rather than “bottom up” or “top down”, but the target, of becoming “paperless by 2020”, is unattainable. Major cultural barriers include resistance by powerful clinicians, who can perceive such strategies as threats to the moral order and their traditional role as gatekeepers of access to patient data. Other barriers include inadequate and delayed national funding; disruption caused by government reorganisations; major premature programme re-structuring and a shift away from the original intent, resulting in the inappropriate selection of single organisation pilot sites rather than multi-organisational community wide ones to promote interoperability. New factors found include: the threats of cyber security incidents and the need for protective measures; the mismatch between strategy timescales and local procurement cycles; the quality of IT suppliers and the competing demands of similar change management programmes for scarce local NHS resources. Proposition: To reflect those findings a new socio-technical model is proposed that incorporates those additional factors as well as two further cross cutting dimensions to reflect “Lifecycle” and “Purpose”, drawing on elements of both Change Management and Technology Lifecycle Theory. “Lifecycle” reflects the “passage of time” as the evidence suggests that factors affecting progress may vary in their presence and impact over time as a strategy moves though its lifecycle. The addition of a “Purpose” dimension supports a reflection on the “why”. Some support is found for the proposal that a “middle out” strategy is more likely to facilitate progress than “bottom up” or “top down” ones. However a shift in approach is advocated. It is proposed that “middle out” e-health strategies are more likely to be successful if their “purpose” shifts away from promoting EHRs, per se, like with single organisation pilot sites, towards inter-organisational clinical and social care workflow improvement across health and social care economies. To achieve that, the focus should shift towards interoperability and cyber security programmes. Those should promote and mandate the use of national interoperability infrastructure, national systems and national standards. They should also provide national funding support to health economy wide clinical and social care workflow improvement pilots and initiatives that span those economies.