This study followed a qualitative, multimethod, collaborative participatory action research design within a constructivist-interpretivist paradigm. The design aimed to explore how clinical and project management staff experienced the implementation of MOTs in a complex tertiary hospital environment [45,46]. Action research was conducted in iterative Plan-Act-Observe-Reflect cycles [47,48], integrating observations, focus groups, and participatory workshops in a convergent triangulation design. Following the action research paradigm, female implementation researchers with backgrounds in clinical medicine, human factors, and information systems acted as the action researchers, whereas female members of the Chief Medical Information Office and the operational project management unit represented the client system. Participants’ accounts were treated as first-order data and interpreted by the researchers to develop second-order concepts [49]. As some team members were involved in coordinating implementation activities, their dual roles not only provided valuable contextual insight but also introduced the possibility of bias. Reflexivity was supported through systematic field notes, joint data collection, and regular team discussions, and analytic distance was strengthened by involving 2 researchers (BK and DF), who had not participated in data collection, in leading the analysis. The study was reported in accordance with the Standards for Reporting Qualitative Research (SRQR; see Multimedia Appendix 1) and the Consolidated Criteria for Reporting Qualitative Research (COREQ; see Multimedia Appendix 2) [50,51].

Before data collection, participants were informed about the study’s purpose, the researchers’ roles, and the goals of the initiative. No formal relationships were established in advance. Researchers were introduced in line with their collaborative roles as action researchers (AN, CG, EH, and LM) and clients (AW, CdP, JCB, and GK) [47]. Professional backgrounds and interest in implementation processes were disclosed, whereas the research questions were not shared.

The study was conducted at Charité – Universitätsmedizin Berlin, a large German university hospital employing over 23,000 staff and operating more than 3000 beds across more than 100 clinics and departments [52].

The research was embedded in the hospital’s digital transformation initiative funded under the German Hospital Future Act (KHZG), which promotes the implementation of DHTs across German hospitals.

Recruitment and data collection occurred from February to April 2025 across 2 implementation phases: (1) a pilot phase observing pre- and early implementation activities and (2) an evaluation phase retrospectively assessing experiences across wards and departments. Together, these stages provided rich insights into the implementation process (Figure 1). Data were collected in inpatient wards, emergency and outpatient clinics, and administrative project management offices.

Access to the field was established by the initiative’s lead via email, drawing on existing professional relationships to promote trust and encourage engagement, as well as through presentations of the initiative in various internal organizational committees. To contextualize these implementation activities, the next section describes the portfolio of digital technologies introduced under the KHZG initiative and examined in this study.

The research was conducted within the framework of the Hospital Future Act, a political mandate that allocates targeted funding to accelerate hospitals’ digital transformation. Hospitals apply for these funds and must comply with national standards for DHTs to be eligible for support [11]. In line with the requirements of the KHZG and the hospital’s overarching digital strategy [53], which emphasizes interoperability, user-centered design, and improved care, a dedicated implementation initiative was launched. Its objective was to introduce 10 preselected MOTs that fulfill KHZG criteria and contribute to the operationalization of the telematics infrastructure, Germany’s secure and interoperable digital health network [54]. These technologies, formally approved as part of the hospital’s digital transformation program, were implemented across inpatient and outpatient departments to enhance clinical documentation, resource management, device integration, and interprofessional communication. Patient-facing or consumer-oriented applications were not included because they were not part of the active implementation portfolio during the study period and thus did not constitute the exposure of interest. The study aimed to investigate the experiences, practices, and challenges of clinical personnel as active users of KHZG-funded MOTs, rather than to evaluate patient experiences or patient-technology interactions. The portfolio comprised both mandatory and optional solutions (see Table 1). Aligning with the action research approach [47], the initiative was iteratively refined in response to contextual factors, including high workloads and limited resources, as well as ongoing adjustments to evolving KHZG regulations.

Participants were clinical staff (physicians, nurses, and patient coordinators) and nonclinical project management personnel involved in or affected by the digitalization initiative.

Eligibility criteria were (1) employment at Charité in a clinical or project management role and (2) involvement in or exposure to at least one MOT implementation. Recruitment followed a multistage purposeful sampling strategy to ensure maximum variation across disciplines and hierarchical levels [65]:

Elements of convenience sampling were used when data collection was integrated into existing meeting schedules.

A total of 129 participants were included: 73 clinicians, 46 project managers, and 10 members of the implementation initiative. While participation was generally high, a small number of invited nurses and physicians declined due to time constraints. Exact numbers of refusals and dropouts were not systematically recorded, as participation was integrated into routine clinical and project management activities. Sampling decisions across all stages aimed to capture diverse perspectives from frontline users and institutional implementers. Units of study were 12 researcher protocols: 5 from observations, 4 from focus groups, and 3 from workshops (see Multimedia Appendix 3). While 129 individuals contributed to data collection activities, analytic inferences were drawn from these protocols rather than from individual participants.

Demographic data were not collected because, following Rapoport’s [43] view of action research as a collaborative, context-bound process focused on collective practice change, roles and functions in implementation were considered more relevant than individual characteristics, and statistical generalizability was not sought.

Primary outcomes were perceived barriers and facilitators to MOT implementation, as well as underlying organizational dynamics that became evident during the process.

Exposures of interest included the characteristics of MOTs (usability, adaptability, and interoperability) and organizational factors (resources, infrastructure, and communication structures).

Potential contextual influences considered during interpretation included differences in departmental resources, professional hierarchies, and workload variation.

All outcomes were derived from qualitative accounts rather than standardized instruments, reflecting participants’ lived experiences and professional perspectives.

The final study size (n=129 participants across 12 protocols) was determined pragmatically, based on data sufficiency, diversity of perspectives, and information power. This approach aligns with qualitative research conventions rather than statistical power considerations [71]. Breadth and representativeness across roles and departments were prioritized over saturation, given the multimethod, organizational scope of the research.

All analyses were conducted at the protocol level, with the 12 researcher protocols forming the analytic corpus. Coding frequencies indicate patterns across activities rather than individual-level quantification, consistent with the study’s action research design [47].

All protocols were transcribed and analyzed in MAXQDA 2022 (VERBI GmbH) [72] using deductive-inductive qualitative content analysis following Kuckartz and Rädiker [73].

To ensure analytic rigor, all coding activities were conducted by product-independent action researchers who were not part of the client system. AN and CG defined a priori codes from the Consolidated Framework for Implementation Research [21,36], guided by prior knowledge of barriers and facilitators. An independent researcher (BK), who was not involved in data collection, then coded the material in MAXQDA, applying these codes and developing inductive ones specific to the MOT context. BK subsequently assigned these codes to either the first-order category MOT implementation barrier or MOT implementation facilitator, with regular review by AN and CG. AN grouped related codes into 12 second-order categories (6 barriers and 6 facilitators), which were validated in 3 team meetings (AN, CG, and LM). To prevent “data overload,” we decided to report only codes with 4 or more coded segments [74]. As Kuckartz and Rädiker [73] do not provide numerical thresholds, these cutoffs were established through analytical reflection to manage data complexity and ensure transparent reporting. This approach aligns with qualitative standards that emphasize conceptual significance over statistical representativeness. A detailed overview of coding frequencies is provided in Multimedia Appendix 5.

Building on preliminary qualitative findings from the different data collection steps, MOT implementation barriers and facilitators also served as a basis for analyzing organizational tensions and deep-seated dynamics. Together, the 3 data sources provided complementary perspectives on the implementation of MOTs. Field observations captured how available MOTs were encountered in practice and how reasons for adoption or nonadoption emerged in everyday clinical and organizational workflows. Workshops contributed to the structured, future-oriented articulation of implementation pathways, including required process changes and strategies for resource-constrained contexts. Focus groups supported retrospective reflection on individual implementation experiences, preferences, and perceived determinants of adoption. Additionally, findings from the different data collection steps were triangulated to inform the interpretation of recurring patterns and contradictions. Based on access to the coded material, LM and DF, who were not involved in data collection and therefore contributed additional analytical distance, independently examined codes for contradictory demands or competing logics (eg, complexity vs participation, resource constraints vs engagement). Findings were discussed in 3 team meetings with AN and CG.

Integrating findings across methods, perspectives, and study phases, the analysis served as the basis for identifying higher-order organizational tensions. As a result, the final conceptual interpretations and tailored implementation strategies were derived from this integrated, triangulated analytical process.

Triangulation of methods (observations, workshops, and focus groups) and perspectives (clinicians, project managers, and implementation staff) enhanced trustworthiness [75]. Reflexivity was maintained through analytic memos and peer debriefing sessions. Quantitative counting of coded segments (frequencies and percentages) was used descriptively to illustrate emphasis, not to infer significance.

Results are presented in 2 sections: (1) 6 integrated second-order categories combining barriers and facilitators within shared aspects of MOT implementation (see Figures 2 and 3) and (2) organizational dynamics conceptualized as 3 tensions. We defined barriers as factors that hinder or prevent uptake and facilitators as enabling conditions that support uptake [25]. Codes and second-order categories were labeled according to participants’ perceptions and our interpretation: barriers were typically described using terms such as lack of, limited, or deficient, whereas facilitators were usually characterized by the perceived presence or availability of a factor.

In total, the coding process identified 390 data segments, comprising 172 barriers and 218 facilitators across the 12 researcher protocols. Frequencies indicate how often themes occurred across protocols and are not intended to represent participant-level prevalence. Multimedia Appendix 5 provides an overview of the distribution of reported and unreported codes, as well as all code frequencies. Representative quotes for all codes can be found in Multimedia Appendix 6. The following sections elaborate on each second-order category, beginning with those related to product characteristics.

This category captures how the functional, technical, and workflow-related characteristics of MOTs shaped users’ experiences.

Barriers arose when MOTs were difficult to operate, poorly aligned with existing routines, or technically constrained. These challenges were reflected in the lack of compatibility (20/172, 11.6%, barriers; 20/390, 5.1%, coded segments), such as when duplicate documentation or parallel paper processes were required. Lack of adaptability (19/172, 11%, barriers; 19/390, 4.9%, coded segments) captured the limited flexibility of MOTs to accommodate diverse wards, workflows, or professional roles. The added value of MOTs was not always evident, as reflected in unclear relative advantage (16/172, 9.3%, barriers; 16/390, 4.1%, coded segments). Difficulties were further reinforced by missing interfaces and fragmented data flows, represented by a lack of interoperability (8/172, 4.7%, barriers; 8/390, 2.1%, coded segments), which required manual bridging and complicated coordination across units. High complexity (25/172, 14.5%, barriers; 25/390, 6.4%, coded segments) referred to multistep logins, unstable Wi-Fi, and slow system responses that conflicted with fast-paced clinical work, as exemplified by a participant describing the mobile ward round:

Facilitators emerged when MOTs aligned with clinical routines and offered clear benefits. Relative advantage was the most frequently reported facilitator (37/218, 17%, facilitators; 37/390, 9.5%, coded segments), emphasizing efficiency gains and reduced communication effort. Compatibility (19/218, 8.7%, facilitators; 19/390, 4.9%, coded segments) supported adoption when system functions fit existing workflows or professional expectations.

Together, these patterns indicate that MOT uptake depended on the extent to which technical design, usability, and workflow integration cohered with everyday clinical practice.

This category captures how staffing levels, protected time, and available support shaped clinicians’ ability to engage in MOT implementation activities.

The most prominent barrier was a lack of dedicated work time for implementation, which accounted for 11 out of 172 (6.4%) barriers and 11 out of 390 (2.8%) coded segments. Participants reported that implementation-related tasks had to be completed alongside routine clinical duties, leaving little opportunity for training, experimentation, or supporting colleagues. As P7 noted: “Enthusiasm is there, but the time resource is missing.”

Facilitators emerged when additional resources or protected time were available. On-site implementation resources represented 7 out of 218 (3.2%) facilitators and 7 out of 390 (1.8%) coded segments, and dedicated work time for implementation accounted for 5 out of 218 (2.3%) facilitators and 5 out of 390 (1.3%) coded segments. Participants described that responsive local support and focused time windows enabled them to engage in implementation activities without competing clinical responsibilities and to incorporate MOTs more consistently into everyday practice.

This category reflects how participants experienced the adequacy and reliability of the hospital’s technical infrastructure during MOT use and implementation.

Barriers were primarily captured in the code-deficient IT infrastructure, which accounted for 11 out of 172 (6.4%) barriers and 11 out of 390 (2.8%) coded segments. Participants described limited device availability, unstable Wi-Fi, slow system performance, and outdated hardware, all of which interfered with routine work and discouraged sustained use of MOT functions. Furthermore, these gaps sometimes prevented MOTs from being implemented in the first place, as required equipment was delayed or unavailable. As one participant noted: “Procurement of technical infrastructure unclear or very slow and bureaucratic via procurement platform” [P3].

By contrast, facilitators emerged when the infrastructure functioned reliably. Adequate IT infrastructure accounted for 7 out of 218 (3.2%) facilitators and 7 out of 390 (1.8%) coded segments. Participants reported smoother logins, stable network access, and consistent availability of clinical information; these conditions supported the routine use of MOTs and reduced the need for workaround practices.

This category captures how the structure, coordination, and support of implementation activities influenced clinicians’ experiences.

Barriers reflected fragmented processes, unclear responsibilities, and insufficient preparation. Lack of cross-unit implementation (5/172, 2.9%, barriers; 5/390, 1.3%, coded segments) and insufficient documentation in technology implementation (4/172, 2.3%, barriers; 4/390, 1.0%, coded segments) highlighted difficulties in understanding which technologies were already in use and how previous rollouts had unfolded. Several participants reported that oversight for implementation had been delegated to local clinical leaders who, due to existing clinical demands, had limited capacity to take on additional coordination tasks, as reflected in the lack of high-level executive responsibility (4/172, 2.3%, barriers; 4/390, 1.0%, coded segments). Reports of lack of technology guidance or training (4/172, 2.3%, barriers; 4/390, 1.0%, coded segments) further contributed to inconsistent processes and limited practical support.

Facilitators emerged when implementation was structured and actively supported. Technology guidance or training was a frequent facilitator in this domain (26/218, 11.9%, facilitators; 26/390, 6.7%, coded segments), alongside implementation support (13/218, 6.0%, facilitators; 13/390, 3.3%, coded segments), process evaluation (9/218, 4.1%, facilitators; 9/390, 2.3%, coded segments), and needs assessment (6/218, 2.8%, facilitators; 6/390, 1.5%, coded segments). Participants emphasized that accessible, context-specific training formats, visible support from the implementation team, and iterative feedback loops helped align expectations and adapt strategies to local workflows: “Planned iterative approach from the start—reminding people, asking about further interaction” [P7].

This category reflects how the availability, engagement, and roles of clinical staff and members of the implementation team were experienced by participants during MOT adoption.

Barriers were reported when individuals lacked time, recognition, or opportunity to participate meaningfully. Lack of participation accounted for 6 out of 172 (3.5%) barriers and 6 out of 390 (1.5%) coded segments. Participants described that, although interest often existed, competing clinical duties limited involvement. Hindering organizational culture represented 5 out of 172 (2.9%) barriers and 5 out of 390 (1.3%) coded segments, referring to hierarchical structures and strained working climates that reduced openness to change. The absence of champions accounted for 4 out of 172 (2.3%) barriers and 4 out of 390 (1.0%) coded segments, indicating missing local multipliers who could support peers or coordinate with the project team.

By contrast, facilitators emerged when individuals—whether clinicians or implementation team members—were available and engaged. Participation accounted for 9 out of 218 (4.1%) facilitators and 9 out of 390 (2.3%) coded segments, with staff actively initiating or supporting MOT rollout activities. Presence of champions represented 6 out of 218 (2.8%) facilitators and 6 out of 390 (1.5%) coded segments, capturing designated or informal multipliers who guided colleagues, tested functions, or liaised with the implementation team. Capability accounted for 6 out of 218 (2.8%) facilitators and 6 out of 390 (1.5%) coded segments, with participants highlighting digital competence and willingness to learn. Engagement accounted for 5 out of 218 (2.3%) facilitators and 5 out of 390 (1.3%) coded segments, reflected in proactive contributions to problem solving or workflow adaptation. A participant summarized the importance of identifiable and engaged individuals: “What else do we need from the clinics? Clear, consistent contacts who can serve as multipliers” [P6].

This category captures how interprofessional coordination and communication practices shaped the implementation of MOTs.

Although participants occasionally referred to coordination challenges, no communication-related barrier reached the minimum reporting threshold of 4 coded segments used in this study. Facilitators, however, were more frequently described and were reflected in interprofessional networking and collaboration, preferred communication channels, and a clear point of contact.

Interprofessional networking and collaboration accounted for 16 out of 218 (7.3%) facilitators and 16 out of 390 (4.1%) coded segments. Participants emphasized that structured collaboration between clinical professions and the project team supported implementation activities, as illustrated by one clinician who noted the value of “bringing different professional groups together to plan the implementation” [P6]. Preferred communication channels represented 12 out of 218 (5.5%) facilitators and 12 out of 390 (3.1%) coded segments, highlighting the importance of using familiar and accessible communication formats, such as in-person briefings, emails, or departmental meetings. A clear point of contact accounted for 8 out of 218 (3.7%) facilitators and 8 out of 390 (2.1%) coded segments, emphasizing the role of identifiable, reliable contacts for resolving questions and maintaining continuity during implementation.

This study identified 3 tensions during the implementation of MOTs.

Tension 1 concerned restricted technological capabilities that did not meet local needs and reduced the perceived relative advantage of the MOTs. Key barriers included product limitations, such as limited interoperability, low compatibility, low adaptability, and high complexity, as well as structural challenges that hindered smooth use. Product alignment acted as a facilitator when MOTs fit existing workflows.

Tension 2 arose from organizational complexity and differing oversight logics that compromised structured user participation. Barriers included a misaligned implementation process and the absence of available individuals to coordinate or support activities. Facilitators included an orchestrated implementation process, effective coordination and communication, and the presence of available individuals who could enable cross-unit participation.

Tension 3 reflected limited resources that undermined individual enthusiasm and interest in implementation. Barriers included resource constraints and a recurring absence of available individuals. Facilitators involved available resources, effective coordination and communication, and the presence of available individuals who could help maintain engagement.

The remainder of the “Discussion” section links these tensions and their respective barriers to misfit theory, introduces the concept of user:ability, and examines how 3 tailored strategies that integrate the observed facilitators respond to the organizational tensions in MOT implementation.

Across all 3 tensions, the findings reveal that hospitals operate in a policy environment that seeks to accelerate digitalization while imposing strict timelines and compliance demands. Examples include Germany’s KHZG and telematics infrastructure requirements [11,54], EU regulations such as General Data Protection Regulation (GDPR) [76] and the upcoming European Health Data Space [77], and US initiatives like HITECH [78] and the 21st Century Cures Act [79]. In this environment, hospitals often rely on MOTs, even though their standardized architecture restricts adjustments to functions, interfaces, or data flows. Limited involvement of end users during early procurement also contributes to systems that later need upgrades or expensive adjustments, as seen with the electronic health record in Germany [80-82]. These dynamics create fertile ground for organization-technology misfits as described by Strong and Volkoff [19]. Such misfits manifest in fragmented tools, disrupted workflows, higher error risk, and increased resource demands for both clinicians and IT teams [83]. In this study, multiple misfits are reflected in, and help explain, the tensions observed.

Tension 1 is characterized by functionality misfits, data misfits, and usability misfits when systems fail to reflect local workflows or information needs. Consistent with prior research, complex authentication [84], complicated user interface navigation [26], misalignment between systems and workflows [29,85], and limited interoperability [86] contributed to usability, data, and functionality misfits. Together, these factors limited the perceived usefulness of the technologies and thus discouraged adoption while also creating workarounds that made the misfits persistent [29,32,33,87,88]. Structural challenges, such as unreliable Wi-Fi, lack of functional devices [31,84], and difficulties complying with interoperability standards, reinforced these limitations.

Tension 2 reflected role and control misfits. Organizational complexity, unclear responsibilities, and inconsistent oversight made structured participation difficult [35,89]. These patterns mirror earlier studies showing that rigid governance structures and unclear responsibilities impede participation [19,90,91]. In our data, clinicians valued early involvement, whereas project managers emphasized clear contact points and department champions.

Tension 3 reflected role and organizational culture misfits. Clinicians were motivated but lacked time, recognition, and resources to take on implementation responsibilities. Resource constraints limited dedicated work time for both clinicians and project managers, a pattern consistent with the comparatively low IT investment levels in German hospitals [92]. Prior evidence supports that high workload and competing priorities force clinicians to prioritize patient care, limiting their capacity to meaningfully evaluate and adopt MOTs [93-95].

Taken together, these misfit patterns allow a focused reflection on the 3 assumptions from the “Introduction” section. The first assumption, that MOT implementation is shaped by functional and usability misfits, is confirmed but should be broadened. Functionality and usability mattered, but their effects were strengthened by role, control, and cultural misfits, showing that challenges arise from clusters of misfits rather than from product issues alone. The second assumption, that MOT implementation requires capacity-building conditions, is supported but needs refinement. Training, participation opportunities, and protected time are not optional but essential to counteract misfits caused by the limited modifiability of MOTs. However, capacity building alone cannot address structural or cultural misfits when organizations lack available individuals or coordination mechanisms. The third assumption, that structural characteristics intensify misfits, is also supported. Structural conditions not only amplified existing misfits; they also created new roles and cultural misfits by limiting participation, creating inconsistent responsibilities, and reducing available time. Overall, successful MOT implementation requires managing technological, organizational, and cultural misfits together, not only improving product alignment or increasing training.

Based on these findings, we introduce the concept of user:ability. User:ability describes the organizational conditions that enable users to adapt to MOTs effectively. It includes targeted training to clarify relative advantage, structured participation supported by clear communication, and protected time that allows users to engage in implementation tasks. Unlike related concepts such as user participation and user involvement, user:ability does not rely on early co-design, which is usually not possible with MOTs. Instead, it focuses on empowering users during implementation. Strengthening user:ability can help address the 3 tensions by improving perceived relative advantage (resolving tension 1), enabling participation in complex settings (resolving tension 2), and sustaining engagement despite limited resources (resolving tension 3). To operationalize user:ability, the following 3 strategies describe mechanisms to mitigate the tensions identified above, drawing on the facilitators observed in this study and integrating prior evidence.

Strategy 1 focuses on reducing functionality, data, and usability misfits by strengthening the perceived relative advantage of the technologies through product alignment, IT integration, and targeted learning.

In this study, relative advantage and compatibility emerged as decisive factors for technology adoption, consistent with diffusion of innovations theory and the Consolidated Framework for Implementation Research [21,36,40]. Tailored learning approaches, including training, local implementation support, process evaluation, and microlearning formats, such as short instructional videos and question-and-answer sessions, helped clarify the benefits of MOT adoption and strengthened user confidence and acceptance [31,85,87,96-103]. As MOTs often require repeated upgrades and costly customizations even after rollout, organizations should integrate MOTs into the IT ecosystem with sufficient in-house IT expertise, enabling real-time access and workflow alignment [104].

Strategy 2 focuses on reducing role and control misfits by creating structures that enable meaningful participation through clear responsibilities, coordination mechanisms, and consistent communication.

Facilitators such as interprofessional networking and collaboration, clear points of contact, and preferred communication channels promoted knowledge-sharing, joint problem-solving, and shared ownership [31,97,100,101,103]. To strengthen these facilitators, hospitals can align IT and organizational goals through a digital business strategy and improve decision-making and coordination through a participatory process model that promotes aligned leadership, adaptive culture, and effective communication [105,106].

Structured and multimodal communication, including intranet resources, structured training, hybrid meetings, and targeted phone calls, can provide tailored support, clarification, and feedback [107]. These measures help align diverse stakeholders, foster trust, and enable coordination across units, thereby reducing role and control misfits.

Strategy 3 focuses on reducing role and cultural misfits by ensuring that individual enthusiasm can translate into sustained engagement through adequate time, support, and recognition.

Hospitals can address these constraints by allocating dedicated resources; providing clear points of contact for clinicians, project teams, and IT support; and structurally embedding clinicians across all phases of implementation [7]. By establishing structured roles such as clinical champions with protected time, for example, 4 hours per week [108], and clear cross-functional points of contact, organizations can sustain engagement, foster ownership, and enhance job satisfaction, supporting effective MOT adoption and evaluation [109-111].

This study contributes to implementation science by moving beyond the common focus on isolated barriers and facilitators. Instead of producing another descriptive list, the analysis integrates the findings into overarching misfits and organizational tensions. This perspective highlights how implementation challenges emerge from structural and relational dynamics rather than from single determinants. The study also introduces the concept of user:ability as an additional contribution. User:ability offers a way to understand how organizations can empower users in settings where technologies allow little adaptation. It shifts the focus from usability to organizational enablement and shows how targeted learning, structured participation, and protected time can help resolve core tensions. This conceptual addition extends existing implementation models by emphasizing the active role organizations play in enabling users to work effectively with MOTs.

While this study focused on barriers to implementing MOTs, the findings should not be interpreted as favoring in-house software development. In-house solutions can involve high development and maintenance costs, limited scalability, and long-term dependence on internal technical expertise and resource commitments [112]. By contrast, off-the-shelf systems benefit from vendor support, regulatory readiness, and standardized functionality, yet implementing them in complex clinical environments frequently requires extensive organizational adaptation to achieve local fit [22,113]. The findings, therefore, do not suggest the superiority of one technological strategy over the other but highlight the need for robust, participatory implementation processes and organizational alignment so that any technology, commercial or locally developed, can be meaningfully integrated into clinical practice.

This study has several limitations that may influence interpretation and transferability. First, researchers held dual roles as implementers and evaluators, which is common in action research but may introduce observer bias. This was mitigated through reflexive practices, independent coding, and triangulation. Second, the analysis relies on frequency-based thresholds to structure qualitative data. Although the thresholds were transparently documented and grounded in established guidance for managing data overload, they may restrict the visibility of less frequent but potentially meaningful insights. As the analysis was conducted at the level of researcher protocols, the findings do not allow conclusions about participant-level prevalence or individual differences.

No demographic data were collected, which limits conclusions about individual differences. While this is methodologically acceptable in action research, where the focus is on collective learning and context-specific change [43], it constrains the ability to examine how individual characteristics may have shaped experiences. The findings, therefore, reflect shared group perspectives within the specific organizational context. Participation was voluntary and may have attracted digitally engaged staff. However, even digitally motivated participants reported substantial barriers, suggesting that the identified tensions reflect systemic conditions rather than the views of a single subgroup. Still, less confident users may be underrepresented.

Some data relied on retrospective accounts, and the short data collection period limited insights into long-term adoption. Moreover, the focus on ready-made solutions may not fully capture upstream influences such as procurement procedures or funding structures. One included technology originated as a local initiative, which only partly aligns with the definition of MOTs but highlights the role of early user involvement.

The study did not include patient-facing technologies and did not collect patient perspectives, limiting insights into how digital transformation affects the care experience. Finally, the study took place in a single, highly resourced university hospital. Transferability is therefore limited, especially to smaller or less digitalized hospitals. Nonetheless, several observed tensions likely resonate across large and complex health care organizations. Future studies should examine these dynamics across hospitals with different structures and digital maturity levels.

This study demonstrates that, in the context of a German university hospital, the successful implementation of MOTs in hospitals depends less on improving usability and more on strengthening user:ability. This reframes digital transformation as an organizational challenge that requires structures that support learning, participation, and engagement when technologies cannot be adapted to local needs.

The 3 strategies derived from the findings provide context-specific guidance for creating such supportive conditions. Their relevance may extend to other large and complex health care institutions, although the implications should be interpreted in light of the single-site setting and the KHZG-funded implementation environment.

More broadly, hospitals must invest in conditions that enable users to work effectively with digital tools. This includes visible benefits for clinicians, coordinated implementation processes for project teams, and strategic resource allocation from hospital leadership.

These insights also extend beyond MOTs. Any digital technology requires alignment between structures, roles, and resources, so the choice between in-house or off-the-shelf solutions is secondary to an organization’s capacity to implement them effectively. Future research should examine how user:ability can be supported across diverse hospital settings to strengthen digital transformation efforts.