ABSTRACT
To address growing geographical disparities in healthcare access and quality, connected health platforms (CHPs) have emerged as promising solutions. However, rapidly scaling CHPs poses significant challenges, particularly in managing tensions among multiple entities. This study examines the digital scaling process of a CHP through the lens of paradox theory, focusing on tensions and their management in resource-constrained environments. We conducted a 13-year longitudinal case study of a CHP encompassing over 300 hospitals in China. Our findings reveal three distinct yet interconnected phases of digital scaling: digital foundation building; system integration and governance; and continuous improvement and innovation. We demonstrate that tensions evolve over time during the scaling process, with one dominant type prevailing in each phase, challenging previous assumptions that different tensions emerge simultaneously across multiple entities. We also identify phase-specific “both-and” responses employed by rural hospitals to manage tensions despite experiencing resource constraints. We provide guidance to organizations operating in resource-constrained environments on the management of paradoxical tensions across a complex digital scaling process.