JMIR Publications

ABSTRACT

Background:

Virtual reality (VR) has demonstrated clinical value across a range of health care applications, yet large-scale adoption of VR-based therapeutic systems remains limited despite decades of supporting evidence. Understanding real-world adoption barriers requires examination of commercially deployed systems in actual clinical practice, a perspective often absent from most prior research.

Objective:

This case study aimed to identify the factors that impeded and facilitated adoption of the REAL System (Penumbra, Inc.), the largest known single-entity investment in medical VR to date, estimated at approximately $1 billion USD across its development and deployment lifecycle.

Methods:

Using an autoethnographic methodology, the three authors drew on their direct experience as Penumbra employees embedded in clinical and commercial operations across dozens of health care organizations over several years. We applied the technology acceptance framework developed by Kouijzer et al to analyze adoption across three stakeholder groups: clinicians, patients, and administrative decision-makers.

Results:

Perceived clinical value and patient motivation were key facilitators of clinician adoption. Barriers included hardware and software usability challenges, workflow disruption, ambiguity of device ownership, absence of validated assessment metrics, and privacy and security compliance requirements. Financial disincentives, particularly the lack of reimbursement pathways under fee-for-service payment models, were the most decisive barrier to widespread adoption. Health systems operating under value-based payment models demonstrated better adoption outcomes. Integration into existing training workflows and clarity of stakeholder ownership were more consequential than prior research suggested.

Conclusions:

Despite substantial investment and demonstrated clinical value, the REAL System failed to achieve large-scale adoption. Successful adoption of medical VR will likely require foundational changes to care delivery and payment models, sustained real-world evidence generation, and coordinated payer engagement. These findings provide an evidence-based blueprint for developers and health systems pursuing VR-based care delivery at scale.