## 1 Introduction  
Information systems (IS) are where Information technologies and Business meet. An information system can be defined as the group of interrelated components that collect, process, store, and distribute information [1]. A Health Information System (HIS) is an IS for the health care sector. Such systems provide benefits from Health Information Technologies (HIT) and components, to produce Electronic Health Records (EHR) as the primary information product. HIS is a core business system for any health organization in addition to other IS providing financial and other operational functionalities. An HIS can enhance healthcare organizations' operations and performance significantly by reducing cost and improving outcomes [2]. Due to their many benefits, HIS are considered crucial to healthcare organizations globally [3]. The information stored in HIS is also used to support decision making and enhancing organizational controls. Business intelligence (BI) and Clinical Decision Support Systems (Clinical DSS) benefit from information stored in HIS to provide both business and medical decisions to improve organizational operations and performance. Patient data in healthcare has the characteristics of 3 Vs of big data, volume, variety, and velocity. Artificial intelligence (AI) and Machine Learning (ML) models can be applied to this patient data to enhance decision-making and provide faster ways for diagnostics and discerning patterns. The insights gained from this analysis can significantly enhance the quality of healthcare [4, 5, 6, 7]. Given the critical role of IS, many methodologies and paradigms have been suggested to improve agility, efficiency, and availability of IS in general. One of these popular paradigms is cloud computing. IS agility in the current environment is critical for the IS to keep up with the ever-changing business requirements. Technological and environmental changes (e.g., regulatory environment, pandemics) require fast changes in IS since most critical business operations rely on IS. HIS face the same challenges of IS agility as well [8]. Cloud computing helps in IS agility in addition to benefits of reducing costs and providing on-demand, bleeding edge, high-performance, and highly available infrastructure, platforms, and software. Cloud computing provides tools and feature sets to achieve Continuous Integration (CI) and Continuous Delivery (CD) to facilitate the implementation of DevOps within an organization. DevOps is a proven methodology to enhance the agility of HIS and IS in general [9, 10] by providing the capability to roll out new and enhanced features in a short time duration in an incremental fashion. With these technologies and concepts, HIS may be easier to maintain and upgrade. These also give new HIS competitive advantage in being faster to the market with new features and functionality. HIS need to be improved so that they are more scalable, highly available, and fault tolerant. All these benefits can again come from the use of cloud computing. However, using cloud computing has its own challenges. These include cost, operations, security, and a complex and fairly new business model amongst others. This study reviews both academic and significant practitioner literature in the field of cloud computing and HIS. It also draws upon the expertise of one of the authors with 6+ years of technology and consulting experience in this area and interviews with experts in Healthcare informatics or Cloud Computing. Based on the review, author expertise, and interviews, three primary dimensions affecting HIS implementation in the cloud are identified. These dimensions are (1) financial performance and cost; (2) IT operational excellence and DevOps; and (3) security, governance, and compliance. Each of these dimensions consist of certain drivers as well as major challenges regarding adoption of cloud-based HIS. The research provides a model that can be used by practitioners to aid decision-making and can be empirically verified.