Abstract
Innovation in healthcare increasingly unfolds within multi-actor ecosystems, yet limited evidence exists about how innovation trajectories are governed through concrete assessment and adaptation practices within these ecosystems. This paper adopts a governance-oriented and processual perspective to examine how decision-making episodes shape innovation trajectories across ecosystem- and case-level dynamics. Drawing on a qualitative embedded case study of the Smart&TouchID (STID) healthcare innovation ecosystem, two sequential governance episodes are analysed: (1) a multidimensional Health Technology Assessment (HTA) of a digital cognitive telerehabilitation platform (RICORDO) structured through the MAST framework, and (2) a subsequent transcultural adaptation process aimed at enabling transferability across three different contexts (Italy, France and Portugal). Findings show that innovation governance is enacted through the interplay between ecosystem-level governance architecture (staged progression, shared evaluative criteria, and distributed roles) and case-based episodes. HTA operates as a boundary-spanning governance mechanism that allow to generate and disseminate multidimensional evidence (clinical, organisational, economic, socio-ethical), that can act also as comparable decision inputs. However, transcultural adaptation exposes the contextual and experiential limits of standardised evaluation: it re-opens the innovation trajectory by foregrounding misalignments in assumptions, usability, and value-in-use across stakeholder groups and national settings. By proposing technology assessment and transcultural adaptation as complementary governance mechanisms, the study shows how these mechanisms alternately stabilise and reconfigure trajectories, advancing a dynamic view of governance-in-practice beyond static ecosystem design.