In terms of time line, there was a gradual step-like increase in the number of articles starting in 2012 and reaching its peak at 20 articles in 2022. The compound annual growth rate (CAGR) was approximately 35%, highlighting the escalating quantity of research into and application of cloud technology in hospitals, as shown in Figure 2. The number of disciplines involved has increased from 1 in 2012 to 10 in 2022, encompassing a total of 22 domains. Specifically, research and application are predominantly observed in the domains of disease monitoring, health surveillance, clinical diagnosis and treatment, safe medication tracking, and medical devices, constituting 51% (48/94) of the overall distribution.

The analysis of 94 articles identified 3 categories and 9 research methods (Table 1). The “technology” category was the most prevalent, with 47 (50%) articles focusing on information systems, cloud platforms, and associated technologies. The “experience” category followed closely, with 40 (43%) articles, primarily validating the performance of or applying cloud-based information systems through empirical research, case-control studies, experience sharing, and cohort studies. Finally, the “literature” category consisted of only 7 literature reviews on this subject matter. The consistent findings of these studies demonstrate the implementation of cloud technology in hospitals can yield positive impact to some extent, such as enhancing precision in management practices, expanding disease monitoring capabilities, reducing workload for medical personnel, and providing convenient and cost-effective health care services for patients. However, 5% (n=5) of the articles also acknowledged certain negative impacts, such as underdevelopment of digital methods in hospitals, cybersecurity risks, and low satisfaction rates among physicians and community pharmacists.

Out of the 94 articles analyzed, the majority (n=49, 52%) focused on task-specific cloud-based systems in hospitals. In contrast, only 21 (22%) articles discussed or developed integrated cloud platforms for sharing within a region, medical alliance, or hospital. Furthermore, as shown in Figure 3, 67% (n=33) of task-specific cloud-based systems were used in patient-related domains such as disease monitoring, health surveillance, clinical diagnosis and treatment, medical care, and medical devices. A total of 15 regional cloud platforms (16%) were commonly used for safe medication tracking, data storage, and medical imaging. A total of 3 medical alliance cloud platforms (3%) found use in disease treatment-related domains such as disease monitoring, clinical diagnosis, and treatment along with medical imaging. A total of 3 hospital cloud platforms (3%) primarily originated from digital hospitals or HIS upgrades.

Because the literature review provided insufficient information to support the analysis of internal and external factors for this study, supplementary materials were collected, including national policies, action plans, white papers, implementation guidelines, research reports, and statistical reports from authoritative websites, such as government agencies, industry organizations, academic institutions, and market research companies. In total, 37 supplementary documents were included in the SWOT analysis: 4 policy papers, 11 industry reports, 15 academic articles, 2 dissertations, 2 official bulletins, and 3 news articles. All of them were recorded in an Excel file (Multimedia Appendix 2).

The United States introduced the Cloud First policy [2] and the CLOUD Act [15]. Similarly, the European Union aims for digital sovereignty through initiatives like the Gaia-X Association and the EU Cloud Computing Strategy [27]. China also prioritized cloud computing as a “national strategic emerging industry” in 2010 and implemented policies to promote its adoption by the government and businesses [28]. Consequently, China has rapidly developed in this field and ranks among global leaders [29].

According to Gartner’s data from 2011 to 2022, the market scale increased from US $95.24 billion to US $491 billion with a CAGR exceeding 16% [30]. The global medical cloud computing market reached US $39.4 billion, with Asia-Pacific exhibiting the fastest growth rate at 22% per year; China and India are significant contributors to this expansion [9]. In China, the market size has surged from less than US $270 million in 2011 to US $66.91 billion in 2022, with a consistent CAGR surpassing 40%, and will exceed US $150 billion by 2025 [30].

According to the National Telemedicine and Connected Healthcare Center of China, as of June 2021, there were 239 million users accessing health care services online and more than 1600 internet-based hospitals in China [31]. Another survey revealed that approximately 63% (n=465) of the surveyed hospitals (738 hospitals across 30 provinces) used cloud services to some extent in 2022 [32]. Moreover, the COVID-19 pandemic has further fueled the demand for online health care services [6]. Consequently, these services have become as commonplace in our lives as online shopping.

By the end of November 2020, China’s population of people aged 60 years and older was 264,018,766, accounting for 19% of the total population, making it the country with both the largest older population and the fastest-aging society worldwide [33]. Consequently, relying solely on their children, nursing homes, or communities to provide older adult care services has become increasingly impractical. Recognizing this challenge, the National Health Commission of China issued a document in October 2019 emphasizing the need to fully harness modern technologies such as cloud computing, artificial intelligence (AI), and the Internet of Things to develop an intelligent service model known as “Internet plus Healthy Aging” [34].

A total of 81 (81%) of the Forbes Top 100 cloud computing companies are American [35], and they possess significant technological and capital advantages. They continuously expand their global market share; they captured 60%-70% (JPY ¥1,725-¥2,012 billion [US $11.6-$13.6 million]) of the Japanese cloud market in 2020 [36] and 69% of the European cloud market in 2021 [37]. The passage of the Clarifying Lawful Use of Data Abroad Act (CLOUD Act) by the US Congress in March 2018 caused European countries to feel threatened due to the potential loss of digital sovereignty [15], which prompted them to initiate their “European cloud” project in 2020 [27]. Other nations may face similar challenges.

In November 2021, 5 bidders for a public cloud service project in Shijiazhuang City, China, submitted bids of CNY ¥0, sparking concerns among stakeholders [38]. The intense competition may lead to unpredictable service performance issues for users, such as limiting hospitals’ access to better pricing and a wider range of choices by restricting the interoperability and portability of HISs or causing sudden disruptions in cloud-based medical services after winning the bid, which poses significant risks to patient safety [16].

Security is the primary challenge for cloud-based systems due to various cyberattacks faced by current cloud environments, especially in the health care sector where sensitive data such as personal privacy, health records, diagnostics, and treatments are stored [13]. Even prominent cloud providers like Azure (Microsoft), Docker Hub (Docker), and Everis (NTT DATA) have experienced malicious intrusions [30], while both the United Kingdom’s National Health Service (NHS) in 2017 and Ireland’s Department of Health information system in 2021 were both targeted and resulted in a complete paralysis [39,40].

To support the implementation of the “Cloud Normal” and “Internet Plus” strategies, the Chinese government has enacted laws, regulations, and management measures. However, there are limited directly applicable legal provisions for cloud migration of HISs. Imperfect laws and regulations, insufficient safety standards, unclear legal liabilities, and the absence of a damage assessment mechanism hinder the proper development of cloud services. As a result, doctors and patients may encounter challenges in protecting their rights during disputes [17].

Hospitals are natural suppliers of big data. For instance, the Chinese National Cloud-Based Telepathology System (CNCTPS) has collected 23,167 cases and served 9240 users in 4 years (2016-2019), providing comprehensive details from whole-slide images to diagnostic reports [5]. Additionally, medical big data can provide substantial value to both hospitals and patients. For example, the aforementioned CNCTPS application can save patients around US $300,000 per year [5]. Abundant electronic health and care records in the United Kingdom’s NHS can reduce hospital operational costs by approximately £5 billion (US $ 3.9 billion) annually and save patient welfare expenses by roughly £4.6 billion (US $3.6 billion) [41]. Furthermore, traditional computing tools are unable to handle the processing and analysis of such massive amounts of data—this is exactly where cloud computing technology excels [18].

Medical services are complex and innovative, requiring synchronization of knowledge, technology, experience, and resources from diverse disciplines. Cloud computing provides extensive connectivity, offering robust support for these tasks, including interdisciplinary expert consultations, collaborative surgeries, and integrating medicine and care [19]. The Huashan Hospital, affiliated with Fudan University, uses a medical consortium cloud platform where experts from higher-level hospitals offer diagnostic advice to lower-level hospitals for subsequent care and daily treatment, ensuring positive outcomes for patients with epilepsy [42].

As shown in Figure 2, cloud technology is receiving increasingly extensive research and application in the medical field, and even some regional or medical alliances have constructed their own medical cloud platforms to store health data, share medical images, and facilitate collaboration. Furthermore, a national survey conducted in 2022 also confirmed these findings by revealing that out of the 738 surveyed hospitals, 63% (n=465) partially used cloud services across nearly 20 different medical business scenarios [32]. These effective practices can serve as valuable references and support for other hospitals yet to implement such initiatives.

The transition from disease-centered to health-centered hospital development in the new era has rendered traditional HISs increasingly inadequate as they were previously designed solely for managing information within hospitals. Cloud computing can significantly expand hospitals’ medical services beyond their physical premises, enabling online chronic disease management, individual life-cycle health surveillance, and remote diagnosis for patients in remote areas. This enhancement empowers hospitals to provide health-centered medical services [20]. The findings of this study also strongly support this notion. As depicted in Figure 3, cloud technology has been extensively used in closely associated domains with patients, encompassing disease monitoring, health surveillance, clinical diagnosis and treatment, and safe medication tracking.

The HISs are the most complex organizational information management systems developed by various contractors in diverse environments, covering a wide range of business functions and user groups [21], as depicted in Figure 3, with only 94 articles included but spanning across 22 distinct disciplinary domains as well. Therefore, the cloud migration of HISs presents significant challenges, particularly for those systems abandoned by development companies due to insolvency or insufficient technical support. Nevertheless, if there existed an all-encompassing and authoritative medical cloud platform enabling hospitals to tailor services based on their specific requirements, it would undoubtedly expedite the overall migration process.

Currently, most HISs still operate in self-constructed networks instead of using cloud-based solutions, which poses information security challenges due to insufficient infrastructure, overreliance on a single protective measure, incomplete regulatory frameworks, and potential vulnerabilities from privilege abuse [22]. For example, the 2019-2020 China Hospital Informatization Survey Report revealed that around 28% (n=282) of surveyed hospitals experienced unplanned core system failures lasting more than 30 minutes [43]. To effectively address these concerns, proficient IT teams like reputable cloud vendors or organizations equipped with advanced technologies such as cloud computing should collaborate rather than solely rely on in-house hospital IT capabilities.

According to Figure 3, more than half of the research articles focused on hospital-specific systems for various tasks. These systems still adhered to traditional information system designs, had limited scalability and functionality, and operated independently. As a result, there were significant challenges in effectively using cloud computing’s computing capabilities, storage capacity, and integrated analysis to generate valuable information supporting government scientific decision-making. The survey results from China’s National Health Commission also confirmed this point as many internet hospitals were not fully developed yet and encountered diverse issues [44]. Moreover, only 14% (n=101) of hospitals had migrated their core business operations to the cloud with a mere 13% (n=100) planning to do so in the next 3-5 years [32]. Therefore, it is crucial for hospitals to reorganize and integrate their operations and resources before incorporating their HISs into the cloud in order to meet the demands of cloud capabilities and new health care models.

With the increasing integration of cloud computing, AI, and robotics, hospitals urgently require highly skilled IT professionals to effectively implement these new technologies [23]. However, a national survey in 2021 revealed that the average number of information department personnel in 9376 secondary and tertiary hospitals was only 6. Most of these personnel held undergraduate or junior college computer degrees and possessed limited interdisciplinary expertise. This falls significantly below national standards [24], particularly for hospitals below grade 2 or in economically underdeveloped areas [45].

According to a 2020 survey by the National Health Commission of China, most primary hospitals allocated less than 1% of their budgets to HIS development, facing challenges such as unstable funding and support [25]. A nationwide survey conducted in 2022 revealed that only 53% of the surveyed 738 hospitals had expenses related to public cloud services in the previous 2 years, with 54% spending less than US $14,000. Particularly for primary hospitals, establishing a cloud service system is even more financially challenging [32]. Clearly, these primary hospitals require more reliable financial guarantees for the smooth operation of their HISs and cloud services.