The Multicriteria Decision Analysis for Extended Reality (MCDA-XR) Governance Framework for Health Care Adoption: Mixed Methods Development Study.

Background: Health services increasingly face decisions about how to integrate immersive technologies into routine practice. International guidance highlights the need for structured governance in digital health, yet extended reality (XR) initiatives are often launched through isolated pilots without a clear assessment of organizational readiness or implementation risk. Although factors influencing XR adoption are well documented, health care organizations and system-level decision-makers still lack practical, governance-oriented tools to translate these determinants into structured strategic decisions made before implementation. Objective: This study aims to develop multicriteria decision analysis for extended reality (MCDA-XR), a strategic governance framework that translates behavioral, organizational, and technical implementation determinants into a structured decision-support process for health care organizations. Methods: The study followed a sequential mixed methods design covering the first 2 phases of a 3-stage framework development and validation project. Phase 1 (identification) defined strategic criteria by integrating theoretical perspectives on organizational complexity, behavior change, technology acceptance, and immersive safety, together with a targeted review of XR implementation evidence. Phase 2 (construction) refined the framework through participatory sessions. A multidisciplinary group of 33 stakeholders, including professionals and managers from hospital and primary care settings, and postgraduate students, evaluated the proposed criteria for strategic relevance and operational clarity. This process resulted in a refined 10-criterion structure and the establishment of a dual-score assessment logic. Phase 3 (validation), planned as a subsequent step, will examine how the framework performs when applied prospectively in clinical settings. Results: The development process yielded a framework comprising 10 operational criteria grouped into 3 conceptual domains (human, organizational, and technical). Stakeholder ratings indicated high strategic relevance across all criteria, with mean scores ranging from 4.03 (SD 0.95) for workflow integration to 4.61 (SD 0.56) for safety and comfort. The final instrument applies a dual-assessment approach in which each criterion is rated separately for strategic importance and organizational readiness. Mapping these dimensions enables organizations to identify priority gaps, particularly areas of high importance and low readiness, and to distinguish between manageable constraints and critical barriers requiring targeted preparatory action prior to implementation. Conclusions: MCDA-XR addresses a key governance gap in XR implementation by providing a structured way to align adoption decisions with institutional priorities and operational constraints. Rather than relying on descriptive feasibility assessments, the framework is intended to support explicit prioritization and action-oriented decision-making at the organizational level. MCDA-XR is positioned for Phase 3 evaluation, which will examine the practical utility, interpretability, and implementation relevance of the framework when applied prospectively in real-world clinical deployments.