## 4 Drivers and Challenges for Cloud Based HIS
### IT Operational Excellence and DevOps  
Application performance can be easily enhanced using cloud computing. Cloud providers make the process of upgrading hardware and operating systems seamless without the need to purchase new equipment or wait for hardware depreciation [48]. Cloudcomputing also allows for on-demand and automatic scaling up or down of resources based on the business use case to accommodate with the needed performance levels based on usage or periodic demand of the applications [49]. Usually, the information and benchmarks for the performance of IS in general are provided in a marketing context and have lacked a scientific basis. They are even more scarce in the context of health care and HIS. More empirical studies are needed to study the performance gains from the use of cloud infrastructure compared to traditional and on premises data center. Additionally, studies need to focus on performance gains and cost-benefit ratio since hardware upgrades are done by the providers. Lastly, auto scaling features and their impact on application performance need to be assessed in more detail and compared with gains from well-forecasted hardware upgrades, with more longitudinal studies to measure the financial impact of these solutions over the long term. Cloud providers are always competing to attract customers by providing their own ready-to-use services and out-of-the-box SaaS and PaaS solutions that will help customers to deliver faster with few details on the underlying components. From a technical point of view, this may lead to a stronger cloud provider coupling, and thus vendor lock-in. As an alternative, many [8,10,50] have suggested the usage of cloud agnostic opensource software tools to facilitate the system movement and migration. Examples of these software tools include Apache Cloudstack ([[https://cloudstack.apache.org/](https://cloudstack.apache.org/)]([https://cloudstack.apache.org/](https://cloudstack.apache.org/)) (accessed on 26 January 2021)), Openstack ([[https://www.openstack.org/](https://www.openstack.org/)]([https://www.openstack.org/](https://www.openstack.org/)) (accessed on 26 January 2021)), ManagelQ ([[https://www.managei.org/](https://www.managei.org/)]([https://www.managei.org/](https://www.managei.org/)) (accessed on 26 January 2021)), Cloudify ([[https://cloudify.co/](https://cloudify.co/)]([https://cloudify.co/](https://cloudify.co/)) (accessed on 26 January 2021)) etc. These tools have been effectively used to decrease vendor lock-in. In this area, comparison between opensource software and cloud providers can be conducted to compare the implications of cloud provider coupling to adoption of opensource solutions from cost, operations, and maintenance point of views, and to more precisely measure the operational overhead and costs of maintaining the in-house open-source cloud agnostic solutions. DevOps [9,51] is an established paradigm in the IT industry for continuous delivery of application solutions to meet market and customer demands. DevOps culture and facilities related to cloud computing not only improve the performance of the application, but also increase the agility and resilience of IS and reduce the financial risks related to downtime and data losses [51]. DevOps deals with the goal of having the development and operations teams work closely together for achieving rapid and continuous release cycles [52]. Application delivery and quality have improved by the way DevOps methodologies develop, build, deploy, and deliver applications. Applications run in containers that are lightweight, isolated, and secured-system processes that share the same operating system to better utilize the system resources [53].