Late Stakeholder Engagement Impacts on Electronic Health Record Transformations within Hospitals and Affiliated Clinics

RAIS Journal for Social Sciences | VOL. 9, No. 2, 2025 ISSN 2574-0245 (Print) | ISSN 2574-1179 (Online) | DOI: 10.5281/zenodo.16922211 ! 140! Late Stakeholder Engagement Impacts on Electronic Health Record Transformations within Hospitals and Affiliated Clinics Samantha THIBODEAU Marymount University, Arlington, VA, USA [email protected] ! Abstract: Electronic health records represent a modern clinical tool that can digitize hospital practices and promote interoperability. Xovap Medical, a pseudonym for a clinical system comprising six hospitals and 24 affiliated clinics, failed to digitally transform toward EHR as a result of later stakeholder engagement. Clinical leaders recognize the need for EHR adoption to facilitate high-quality patient care, promote diagnosis accuracy, and modernize outdated workflows. A narrative literature review was conducted to understand successful strategies for EHR adoption when engaging stakeholders and the risks associated with late engagement. The review suggests early stakeholder engagement as a critical component in successful EHR transformations. The findings suggest leaders must engage physicians to help select EHR tools, utilize physician knowledge to inform training, promote feedback cycles that help sustain EHR adoption, and build trust that the EHR provides high-quality patient care through involvement in the adoption process. Keywords: EHR Transformation, Technology, Hospitals, Efficiency, Stakeholder Engagement Introduction Xovap Medical, comprising six mid-sized hospitals and 24 clinics, sought to digitally transform its operations by adopting electronic health records. Leadership outlined three goals for the transformation towards EHRs: improved quality of patient care, increased interoperability, and enhanced data analytics capabilities. Mounting pressures to digitize their processes, leading to shortcuts, have diminished their change management process. Within the shortcuts, late stakeholder engagement contributed to skepticism, which ultimately led to the digital transformation failure. Ultimately, the lack of support among physicians resulted in resistance to EHR adoption, costing Xovap Medical money, time, and trust. Today, hospitals and healthcare systems such as Xovap Medical seek to transform their medical reporting toward EHRs. The Health Insurance Portability and Accountability Act, introduced in 1996, initiated the digital transformation of patient health records (Adekunle et al., 2025). HIPAA introduced the idea that ease of information exchange via digital means would increase the quality of patient care across hospitals and private offices (Adekunle et al., 2025). Electronic Health Records (EHRs), the resulting digital solution to achieve HIPAA compliance, represent modern practices for storing patient health information to enhance communication between providers, improve the quality of patient care, and ensure accurate data (Palabindala et al., 2016). HIPAA represented a fundamental shift in clinical policy, raising the need for clinical leaders to address digital change within their hospital. Leaders must reimagine clinical workflows and focus on interoperable THIBODEAU: Late Stakeholder Engagement Impacts on Electronic Health Record Transformations within Hospitals and Affiliated Clinics ! 141! systems that enhance communication. Clinical leaders now face technological and organizational considerations when adopting an EHR. As hospitals and practices look to shift towards EHRs, understanding the importance of stakeholder involvement remains critical. Adopting a new healthcare process, especially one that utilizes digital means, requires consideration of change management. Leaders seeking to increase the adoption of EHRs must design systems that meet the needs of users and incorporate their feedback (Heath & Porter, 2019). Stakeholder engagement, often with physicians, remains critical to an in-depth understanding of how to impact the culture of a hospital (Talwar et al., 2023). Failure to consider the end user and stakeholders results in resistance to digital transformation, leading to increased costs, limited adoption, and extended timelines for modernization (Heath & Porter, 2019). Overall, healthcare organizations seeking to transform their operations through the use of an EHR must consider user feedback to ensure the successful adoption of new processes. Problem Statement As of 2021, only 70% of hospitals have adopted an interoperable EHR, leaving the remaining without standardized health record practices (Barker et al., 2023). Moreover, as of 2023, only 70% of hospitals engage in the four measures of interoperability, including sending, receiving, finding, and integrating patient health data (Gabriel et al., 2024). Offices lacking interoperability experience stagnation or declines in the quality of patient care, an increased risk of outdated patient health histories, and reduced government funding and incentives (Adekunle et al., 2025). The generic problem remains that hospitals and private practices struggle to digitally transform their operation, leading to failures in adopting an EHR system. The specific problem is that EHRs do not meet user needs, rendering them infeasible for day-to-day operations due to a lack of physician engagement early in the transformation. The literature review seeks to address the research question “How does late stakeholder involvement hinder EHR adoption, and what strategies can facilitate successful digital transformation towards EHRs in hospitals and clinics?” Significance The significance of the study lies in identifying impacts to EHR transformations when involving stakeholders too late in the process and exploring strategies to mitigate adoption resistance. Hospitals and clinical systems looking to modernize and receive government incentives must convert to an EHR (Adekunle et al., 2024). To successfully adopt a new EHR into a healthcare system, leaders must gain physician buy-in. Physicians cannot provide quality patient care when they have limited involvement and transparency in significant process changes (Miller, 2017). The importance of EHR adoption lies in hospital operational success and increasing patient quality of care. By understanding the negative impacts of Physician exclusion, leaders can identify the risks to change management associated with EHRs. Furthermore, understanding the ramifications of excluding physicians from initial transformation plans helps leadership improve its digital transformation strategy (Holmgren et al., 2022). Identifying theories that clinical leaders can apply to EHR transformations aids in strategy development (Holmgren et al., 2022). The techniques inform stakeholder inclusion, process considerations, and best practices for user adoption, all of which allow clinical leaders to build sustainable practices involving EHRs. Ultimately, the study examines the significance of stakeholder involvement in conjunction with operational models in developing a digital EHR transformation strategy. RAIS Journal for Social Sciences | VOL. 9, NO. 2, 2025 ! 142! Methods Databases and Sources Used The literature search included research databases such as ProQuest and Google Scholar. Google Scholar was the primary source for all peer-reviewed journal articles, books, and conference papers. ProQuest identified all dissertations relevant to the study. Grey literature encompasses reports and conference proceedings that are relevant to the discussion topics. The methodology for the study includes a systematic literature review focused on understanding the complexities of digital transformations of hospitals toward EHRs. The primary search terms used for the literature review included "Electronic Health Record", "EHR", "Digital Transformation", "Healthcare Digital Transformation", "EHR Adoption", and "Digitizing Healthcare". Terms such as "EHR" and "Electronic Health Record" were selected because they are the primary focus of the digital transformation at Xovap Medical. Terms such as "Healthcare Digital Transformation" and "Digitizing Healthcare" were chosen as secondary terms to broaden the literature review and examine characteristics of transformations that occur because of EHR implementations. The search results in information about the core topics of the review, including electronic health records and the adoption of EHRs in a hospital's digitization plan. Furthermore, search terms contained the AND Boolean to identify sources that used a conjunction of the terms, including "EHR" AND "digital transformation". Utilizing Boolean terms such as "EHR" and "digital transformation" helped identify articles not part of single search terms and allowed for enriched sources focusing on organizational aspects of change in healthcare that focus on EHRs. Additionally, the Boolean operator "OR" was used to find articles under different nomenclatures about an identical topic, for instance, "EHR" or "electronic health records". The inclusion of "OR" search criteria helped find articles that mentioned the same topic but referenced it differently to ensure a comprehensive search for electronic health records was conducted. Finally, the use of synonyms increased search results but required additional analysis to ensure adherence to the topic. ! Inclusion and Exclusion Criteria The included studies must provide empirical data on Electronic Health Records, the adoption of Electronic Health Records, or digital transformations in healthcare within the last 10 years (2015-2025). The date range allows the study to encompass long-term impacts of EHR adoption and to include relevant assessments from today's clinical climate. Furthermore, sources must have clear, direct, and focused research questions that utilize a substantiated research approach. An emphasis was placed on ensuring the validity of the research method and approaches taken by the researchers. Journal articles focusing on private practices were excluded due to lack of relevance towards Xovap Medical EHR adoption. Studies lacking a literature-supported methodological approach, clarity of approach, or direct relationship to the topic under investigation were also excluded. ! Screening and Selection Process The initial search yielded 745 articles. Screening focused on identifying titles that contained the key search terms using the "AND" Boolean operator. The result yielded a total of 75 articles needing full-text review. Each article was analyzed primarily for its relevance to the topic. The resulting filtered articles were then assessed for the academic rigor of the study and the comprehensive understanding of the topic. Articles that solely mentioned a term on the surface but did not have depth of information were eliminated. Finally, Xovap Medical is a mid-size system comprising a set of hospitals and affiliated practices. Therefore, articles needed to reference hospital transformations and contain a rigorous approach. The results comprised 53 articles. THIBODEAU: Late Stakeholder Engagement Impacts on Electronic Health Record Transformations within Hospitals and Affiliated Clinics ! 143! Literature Review Electronic Health Records History Physicians historically documented patient medical records using paper-based charts (Evans, 2016). Around 1990, it became apparent that a comprehensive health record did not exist (Evans, 2016; Lorkowski & Pokorski, 2022). Physicians relied on a combination of digital and non-digital resources to create a patient’s health snapshot (Lorkowski & Pokorski, 2022). Eventually, electronic health records (EHRs) were able to meet the needs of physicians to integrate notes, prescriptions, test results, patient messaging, and imaging within a single platform (Evans, 2016). The limited number of adopting hospitals found standardization difficulties. Thus, the Universal Medical Language System (UMLS) and Health Level Seven (HL7) were built to guide the terminology and build integration standards between EHR systems (Evans, 2016). In 2009, the Clinical Health Act (HITECH) introduced new standards for patient care facilities via digital platforms (Lorkowski & Pokorski, 2022). The act focused on the adoption of EHRs in hospitals, encouraging practitioners to provide increased quality care, care coordination, and health information exchange (Adler-Milstein & Jha, 2017). HITECH incentivizes clinical systems to digitally transform, offering financial bonuses when the transformation demonstrates “meaningful use” (Gettinger & Zayas-Caban, 2021). The criteria for qualification set standards for the digital transformation and require an assessment before hospitals receive the incentive (Adler-Milstein & Jha, 2017; Gettinger & Zayas-Caban, 2021). The history of EHRs underscores the importance of centralizing patient historical information, a concept that has gained government support over time. Importance of EHR Transformations Patient Care Quality The importance of an EHR transformation at Xovap Medical lies in providing quality patient care. Physicians desire to deliver quality patient care (Kruse et al., 2016). By centralizing patient information into a digital platform, providers can make data-driven decisions (Upadhyay & Hu, 2022). Updating data in real-time ensures a comprehensive health record that allows physicians to increase diagnosis accuracy (Amlung et al., 2020). The accuracy of diagnosis instills patient confidence in care and strengthens the patient-provider relationship. Thus, establishing quality care through informed decision-making. Communication between Providers and Patients EHRs facilitate better communication between physicians, directly impacting the quality of care (Upadhyay & Hu, 2022). Wass et al. (2019) highlight that patients utilizing health portals have increased communication with providers. The EHR portals provide easy access to information (Wass et al., 2019). Increased communication fosters well-rounded treatment programs grounded in accurate and complete data (Spatar et al., 2019). Patient perceptions of quality care can increase through EHR adoption by making patients responsible for their health outcomes (Wass et al., 2019). Thus, increasing physician confidence in the EHR (Spatar et al., 2019). The quality of care from increased communication represents a primary impetus for EHR digital transformations. Hospital Modernization Furthermore, EHR transformations provide hospitals with opportunities to modernize and secure government funding for this purpose. To remain reputable and retain funding, modern hospitals must adopt EHRs (Amlung et al., 2020). Clinical settings must adopt digital practices to keep up with evolving healthcare demands and enhance data-driven decision making (Amlung et al., 2020). The adoption requires redesign of processes that promote RAIS Journal for Social Sciences | VOL. 9, NO. 2, 2025 ! 144! innovation and keep the hospital utilizing new technology (Upadhyay & Hu, 2022). Also, the HITECH Act helps promote the adoption by offering incentives toward modernizing hospitals (Kruse et al., 2022). The funding helps offset costs associated with EHR transformations, enticing individuals to modernize their organization (Kruse et al., 2022). EHR adoptions create conditions to modernize practices and help clinical settings remain in business. Clinical Care Efficiencies Finally, the significance of EHRs lies in enhancing workflow efficiencies. Introducing EHRs can streamline efficiency by aligning the tool to physicians' workflows (Kruse et al., 2022). The system design can enhance clinical routines, create efficiencies such as streamlined prescription ordering, and reduce documentation errors (Spatar et al., 2019). EHRs also help reduce redundancy and repetition through automation (Upadhyay & Hu, 2022). Workflow efficiencies contribute to a reduction in the time spent on the process, which in turn improves patient care outcomes (Kruse et al., 2022). The use of EHRs as a mechanism to facilitate efficiency motivates clinicians to adopt the new practice. ! Benefits of Successful EHR Transformations Harnessing effective change management remains a critical factor of successful EHR transformations in hospitals. Barrett and Stephen (2018) found that individuals benefit when leadership considers the socio-technical aspects of change management. Both components are critical to the successful adoption of EHRs and directly apply to the resistance MeridianHealth faced in its initial adoption. Social Benefits of Successful EHR Adoptions Social aspects of change management focus on the individual, their interactions, and feelings around the EHR adoption. Impacted individuals benefit from communities supporting the change (Barrett & Stephens, 2017). Communities promote centers of learning and prompt a shared commonality of learning something new, together (Sieck et al., 2020). During group trainings, individuals ask questions, share tips, and raise important concerns before the EHR adoption phase (Sieck et al., 2020). The transformation facilitates a profound sense of community within a hospital system and enhances acceptance of change (Barrett & Stephens, 2017). Gatiti et al. (2021) found that successful EHR adoption leads to increased transparency and shared responsibility of the tool. Xovap Medical, if successful, can establish a community of clinicians advocating for successful EHR adoption. Successful EHR adoptions improve communication among the adoption team. Patient Care Outcomes Fully integrated EHRs with complete adoption can improve patient quality health outcomes. EHRs facilitate enhanced data exchange patterns that centralize information and share across hospital systems (Jiang et al., 2023; Sieck et al., 2020). Effective integrations also promote sharing between physicians, healthcare systems, and public health agencies (Jiang et al., 2023). The continual streams of relevant data allow clinicians to make appropriate, informed diagnoses. Thus, increasing transparency around diagnosis and treatment plans and strengthening patient perception of quality care (Cifra et al., 2021). Patient feedback directly impacts physician confidence in the tool’s ability to provide information (Jiang et al., 2023). At Xovap Medical, a successful adoption could solve concerns about data relevance and diagnosis accuracy. The circular relationship cements the importance of successful EHR transformation in increasing patient care quality. THIBODEAU: Late Stakeholder Engagement Impacts on Electronic Health Record Transformations within Hospitals and Affiliated Clinics ! 145! Impacts of Late Stakeholder Involvement Design Flaws Design flaws ensue when stakeholder engagement occurs too late in the digital transformation process (Palabindala et al., 2016). Each hospital functions differently, and tools must support the complexity of the Physician's day (Heath et al., 2022). Without constant feedback and iteration when selecting and implementing the EHR, hospitals may find tools that lack all necessary features to ensure quality patient care (Gesulga et al., 2017). The design discrepancies that render EHR tools unusable (Palabindala et al., 2016). Perception of EHRs' ease of use and efficiency among physicians diminishes when the EHR cannot support basic workflows (Gesulga et al., 2017). Effective involvement, at Xovap Medical, should include opportunities to modify workflows, customize settings, and identify avenues the tools can meet physicians' clinical needs to support patient care (Heath et al., 2022). The lack of accommodations in the software poses a significant risk to tool adoption due to the infeasibility of the solution to meet usability expectations. Workflow Disruptions Redesigning daily work streams to accommodate an EHR presents another risk that plagues Xovap Medical. Physicians adopting EHRs face a loss of autonomy through reduced control over how to structure their workday (Barrett, 2018). Work routines signify critical components of a successful patient-provider relationship, allowing physicians enough time to provide quality care to the patients on their schedule (Malm-Nicolaisen et al., 2022). With little input on how an EHR impacts work, physicians feel powerless over the changes (Barrett, 2018). By introducing new tools without their involvement, physicians must maintain the same patient load, uphold quality care, and additionally redesign all working patterns (Barrett, 2018). Even if the product meets all the hospital's needs, the adoption process takes time to incorporate new technologies into established workflows, causing disruption (Gesulga et al., 2017). With already busy schedules, physicians struggle to reserve time to adopt a new tool, which requires slowing down to learn something new (Gesulga et al., 2017; Heath et al., 2022). This results in increased resistance through slow or partial adoption, threatening patient care quality and interoperability of data. Such is the case for Xovap Medical, which faces partially adopted systems impacting care quality. Late physician involvement creates a loss of professional autonomy, threatening EHR adoption. Detriment to Patient–Provider Relationship Furthermore, EHRs designed without consideration for environmental impact can compromise the patient-provider relationship (Eberts & Capurro, 2019). Physicians establish trust and respect within the community by building rapport with patients. EHR adoption requires shifting focus from patients to incorporating tools (Barrett, 2018). Physicians with late involvement in digitization cannot properly prepare for patient impacts (Barrett, 2018). EHRs that do not facilitate communication erode patient trust, which directly impacts physician reputation and leads to a lack of adoption (Eberts & Capurro, 2019). The resistance to change increased when physicians sense patient dissatisfaction (Heath et al., 2022). At Xovap Medical, mounting resistance, stemming from perceived lower-quality care and the loss of patient-provider relationships, resulted in EHR adoption failure. Threats to communication and strong patient-provider relationships weaken EHR adoption efforts. Legal Liability Concerns Finally, physicians have concerns about autonomy as it relates to their liability in patient safety and diagnosis. EHRs serve as an aid for government-compliant medical record documentation and also contain features that aid in diagnosis and treatment plan suggestions (Gesulga et al., 2017). The potential for misdiagnosis raises concerns about physician RAIS Journal for Social Sciences | VOL. 9, NO. 2, 2025 ! 146! liability when relying on digital tools. Physicians remain responsible for patient care, and being involved late in a fundamental shift in how they diagnose patients causes resistance (Keshta & Odeh, 2021). Physicians do not want to be held liable for misdiagnosis resulting from the misuse of software (Gesulga et al., 2017). Improper diagnosis has legal and reputational implications, both of which lead to initial distrust of an EHR (Gesulga et al., 2017). Physicians must consider the ethics around the data they create and store to ensure proper adherence to HIPAA (Hare, 2022). Xovap Medical’s lack of proper collaboration during the initial phases of the transformation increased risks of misuse and impacts liability risk for physicians (Gesulga et al., 2017; Keshta & Odeh, 2021). The risks associated with misuse resulting from improper training and guidance lead to a lack of trust in the EHR and stop adoption. Ultimately, late engagement of physicians does little to address data security and liability considerations that impact EHR adoption. Impacts to Training and Adoption Training creates a shared environment focused on transitioning teams towards a new process. Gesulga et al. (2017) report that many physicians lack opportunities for training. Sometimes physicians receive training but find that the training does not focus on tangible examples (Barrett, 2018). Physicians' specializations often require specific considerations, and training lacks the flexibility to address user concerns (Barrett, 2018; Heath et al., 2022). Instead, generic trainings cover a wide breadth of information without depth or tailoring to the adoptees (Gesulga et al., 2017). The widespread confusion created by this issue leaves professionals unsure about how to use the product and struggling to find the critical reporting measures required to meet the HITECH Act (Malm-Nicolaisen et al., 2022). Such difficulties result in physicians misinterpreting the intended user of the EHR, compromising quality care and proper practices for shortcuts that endanger patient safety (Heath et al., 2022). Without confidence in using the system, physicians will find workarounds or revert to relying on paper-based charts rather than embracing digital transformations towards EHRs (Gesulga et al., 2017). Late stakeholder involvement can impact training effectiveness and diminish confidence in the EHR. ! Social Barriers to Adoption Xovap Medical’s EHR transformation suffered from a lack of confidence and credibility with its stakeholders. Physician involvement late in the process poses two fundamental risks towards digital transformation: Skepticism and Lack of Trust (Bakhshi et al., 2025; Heath et al., 2022). When adoptees' curiosity rises with little to no direct addressing of concerns, the increase in skepticism will sink any progress made towards change management (Sadoughi et al., 2019). Trust, if any already exists, diminishes as questions go unanswered and stakeholders are left confused as to the purpose and progress of the transformation (Bakhshi et al., 2025). The barriers led to the failure of Xovap Medical EHR transformation. Skepticism Impacts Skepticism represents an inherent lack of transparency around the digital transformation towards EHRs (Heath et al., 2022). Often, the unknown centers on why a change must occur (Malm-Nicolaisen et al., 2022). Gesulga et al. (2017) note that a root cause of skepticism is the effectiveness of the EHR in providing patient care. Bakhshi et al. (2025) highlight additional skepticism that arises around unanswered expectations of the EHR and the uncertainty associated with change management when transitioning to an EHR. Failing to identify a technical partner early in the project leads to increased confusion and resistance from individuals expected to adopt the new technology (Giussi et al., 2017). Mounting skepticism leads to resistance among staff and management, which can hinder all plans for change management (Gesulga et al., 2017). Failure to increase transparency through clear communication, direct addressing of concerns, and early stakeholder involvement often THIBODEAU: Late Stakeholder Engagement Impacts on Electronic Health Record Transformations within Hospitals and Affiliated Clinics ! 147! leads to transformation failures (Saldanha, 2019). Xovap Medical's physician suffered from a lack of transparency, which raised skepticism and ultimately sank the transformation process. Skepticism impacts successful EHR adoption by hindering progress and eroding trust. Lack of Trust The lack of communication around changes prevents trust and resistance (Heath et al., 2022). Transparent communication functions on two levels: Leaders to Physicians and Physicians to Patients. Without both critical communication channels, people will not believe that EHR transformations benefit them, nor will they maintain quality care (Talwar et al., 2023). Physicians possess the technical skills to translate medical concepts from the EHR to the patient, as well as the soft skills necessary to adopt and integrate the EHR into their workflow (Talwar et al., 2023). Involving physicians late in the transformation degrades trust because it debilitates a central communication checkpoint between all stakeholders (Deokar & Sarnikar, 2016). Deficiencies in transparent communication result in a higher barrier towards change management and lead to transformation failures (Saldanha, 2019). Xovap Medical suffered from a lack of stakeholder engagement, which cut off communication channels and stalled adoption. Clear communication has a direct impact on physicians' trust and willingness to adopt an EHR. ! Impact of Failed Digital Transformations on Organizational Health Organizations, such as Xovap Medical, that fail to successfully transform toward using an EHR find continual resistance leading to reversion to old patterns (Vanderhook & Abraham, 2017). EHR tools that do not facilitate appropriate user workflows cause physicians to compensate for missing functionality (Colicchio et al., 2019; Vanderhook & Abraham, 2017). For example, reverting to paper documentation outside of the EHR platform can facilitate documentation shortcomings (Colicchio et al., 2019). Some clinical settings maintain a hybrid model, finding workarounds within the EHR to achieve a desired outcome (Colicchio et al., 2019). The practice undermines the intent to modernize patient health records and introduces more barriers to change management (McCrorie et al., 2019). Specifically, a failed transformation creates increased resistance in the next iteration, due to the fear of having to repeat a process and not learning from the original mistakes (McCrorie et al., 2019). Initial failures of an EHR adoption leave lasting impacts and increase resistance for the second attempt. Ethical Considerations around Digital Transformations to EHRs Patient Data Privacy Holistic digital transformations towards EHRs require ethical consideration before implementation. Clinical leaders need to address concerns around patient data privacy (Hare, 2022). Clinicians should only share Personal Health Information (PHI) with relevant clinicians, and clinical leaders must limit access to EHRs to relevant personnel (Agarwal & Peta, 2024). Hospital leaders at Xovap Medical must ensure that EHR tools offer data privacy and protection policies that can be enforced across their clinical systems. Failure to properly enforce data policies will result in the leakage of PHI, leading to legal ramifications that will halt the EHR transformation entirely (Agarwal & Peta, 2024; Keshta & Odeh, 2021). Patient’s perception of data exposure will also weaken confidence in the tool and impact physician willingness to champion the change (Keshta & Odeh, 2021). Overall, data protection and privacy require consideration before EHR adoption. ! RAIS Journal for Social Sciences | VOL. 9, NO. 2, 2025 ! 148! Ethical Training Another consideration for Xovap Medical is to include ethical training when adopting an EHR. The Hippocratic Oath or the ethics behind the oath need consideration (Hare, 2022). Hare (2022) finds that society asks doctors to uphold ethical standards when treating patients however, medical technology does not require consumers to take an ethics-related course or oath to be utilized (Hare, 2022). As the message's criticality increases, so must the scrutiny with which we select our target user population (Hare, 2022). Life-threatening actions need rigorous user testing to ensure the tool minimizes the risk of oversight and maximizes quality patient care (Gesulga et al., 2017). Designing health-based software requires attention to ensure the ethical protection of the software users and the data (Keshta & Odeh, 2021). Failure to account for usability and test thoroughly to ensure the protection of society results in a life-threatening, unethical technology. ! Effective EHR Feedback Loops Ongoing Feedback Loops Acquiring feedback requires outlining specific processes that allow for trust and open communication. Cifra et al. (2021) highlight effective feedback characteristics to include accuracy, consistency, time-relevance, delivery, and possibility for iteration. Moreover, effective feedback prompts additional conversations on how to incorporate or resolve concerns raised in the initial session (Cifra et al., 2021). Leaders seeking information should conduct feedback studies as close to the clinical event as possible and deliver the sessions that limit cognitive load (Cifra et al., 2021). Xovap Medical failed to engage with physicians promptly, and thus, the feedback they received offers little insight into the EHR transformation. Instead, clinical leaders at Xovap Medical should have established feedback loops throughout the EHR transformation with regular checkpoints to ensure smooth adoption (Golden et al., 2021). By including feedback on technical and ethical concerns, clinical leaders could have decreased adoption resistance, prompting a smooth EHR transformation. The feedback loop and scope remain a critical components of successful EHR adoption. Product Design Feedback Loops Physician engagement aids product design by identifying necessary features of the tool. Product-behavior focused feedback loops ensure EHRs meet the workday needs of clinicians (Cifra et al., 2021). The loops provide a platform for improvement, feature requests, and customizations that enhance the physician experience with the EHR (Cifra et al., 2021). For example, effective processes for gathering feedback can include preor post-implementation testing and usability interviews (Tutty et al., 2019). The continuous feedback identifies areas of improvement to ensure that quality patient care remains at the forefront (Iseal & Frank, 2024). Successful feedback mechanisms facilitate improved adoption rates because tools meet the feasibility of the physicians (Gatiti et al., 2021). Effective product feedback loops ensure EHRs remain relevant to the hospital and reduce misuse. Post-Implementation Feedback Loops Maintaining leadership and physician alignment requires a feedback loop to sustain EHR transformations. Iseal and Frank (2024) find that progress updates help inform clinical leadership of impediments encountered after fully adopting an EHR. These ceremonies facilitate strong relationships between leadership and frontline workers (Golden et al., 2021). Some examples include engaging physicians through consultation sessions, surveys, interviews, and focus groups with the goal of process improvements (Tajirian et al., 2022). Tajirian et al. (2022) also found a monthly newsletter to be an effective feedback channel to keep physicians informed and gather feedback for reinforcing strategies of EHR adoption. THIBODEAU: Late Stakeholder Engagement Impacts on Electronic Health Record Transformations within Hospitals and Affiliated Clinics ! 155! Malm-Nicolaisen, K., Fagerlund, A. J., & Pedersen, R. (2022). 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