## 4 Drivers and Challenges for Cloud Based HIS
### Financial Performance and Cost  
Operational excellence and efficiency are some of the main advantages of using HIS, which leads to increased financial performance [41, 42]. Financial performance of health organizations can be enhanced by using cloud computing to modernize HIS through efficiency gains and operational and capital cost reduction as discussed previously. However, the use of cloud may also have unexpected or hidden cost components such as migration costs and application management costs, which may increase costs dramatically. From the cost perspective, pay-as-go and on-demand pricing model [28, 43] of the cloud reduces the startup cost for design, implementation, and management of the IT infrastructure. This pricing model has attracted many firms [8, 28], especially startups to adopt cloud computing. The literature mostly focusses on how business has shifted to cloud computing for cost benefits but has less focus on how the pay as go model may lead to high-cost drifts especially if it is unmonitored [44]. Empirical studies are needed to compare costs between well architected on-premises datacenters with a proper expansion forecasting to host HIS as compared to the pay-as-you-go model of the cloud providers. Also, more studies on customer satisfaction with cloud providers' billing and costs in multiple industries including healthcare need to be conducted to measure the cost benefits of cloud solutions and to have a reliable estimation of how much saving cloud computing adoption can lead to. Another area that is worth investigating is the various pricing schemes provided by the cloud providers. Pay as you go and on-demand pricing have been the primary focus in  
Figure 1: Cloud computing opportunities and challenges. the literature; empirical studies are needed to study the adoption models of other pricing schemes like reservation, leasing, and excess capacity usage. Reservation and leasing are a commitment to use predefined computer resources for a specific duration, and excess capacity usage is the use of idle and already running computer resources until they were reclaimed when needed by the providers [45, 46]. Cloud providers market these schemes as they provide a respected amount of savings [45, 46]. Organizations that have conducted a detailed load study of their resource requirements can benefit from such schemes through various automated provisioning tools. A reduction in operational costs needed to manage and maintain internal datacenters [28, 43] is another advantage of using cloud computing, however, more focus may be needed on the financial effects in situations such as service outage since the maintenance and support are provided by the cloud vendors and not by the institution itself. Cloud service outages are well known [47] and make big news as they happen. However, the big news is usually in the media when consumer end services like Gmail and others are affected. Statistics pertaining to corporate downtimes are not available since the data may not be disclosed. In the case of HIS, even a few minutes of downtime can create issues. When the HIS is hosted outside the organization, then the amount of uncertainty and feeling of loss of control can compound the situation. Information in HIS is lifesaving and availability of data should be guaranteed, therefore, more empirical studies need to be conducted on the satisfaction of the uptime, service availability, and support levels provided by the cloud vendors in the context of healthcare institutions. Interviews with financial leaders and consultants (1,2,11) helped in arriving at the financial performance and cost factors. The CFO (11) focused on the yearly budget for cloud computing while the financial auditors (1) focused more on the amendments to budgets because of unexpected costs and the unmonitored usage of cloud computing.