therefore , it is necessary for the designers of information technology and communication systems to assess them continuously .
however , it is impossible to evaluate such systems without first analyzing their users understanding of them .
an information system is a combination of technology , individuals and processes used to transport , store , manipulate and present data .
health information refers to the organized data related to a patient or a group of patients .
healthcare information systems include data and concepts in health services given to patients to improve the management of such services .
hospital information systems have many functions such as patients admission , transfer and discharge as well as financial and clinical affairs [ 68 ] .
there are many advantages to health information services : the enhancement of medical care quality and reduction of costs and errors .
most evaluations performed in this field have focused on the reduction of costs and the improvement of quality .
hospital information systems ( his ) have many advantages : they increase the quality of medical care and reduce costs and clinical errors . however , despite all these benefits , information systems have also some problems .
in fact , evaluation in an endless process   and its results can be used to make decisions regarding the required investments for designing hospital information systems .
it is necessary to consider the evaluation of hospital information systems before , during and after developing them .
there are many articles focusing on the evaluation of health information systems , as well as their indicators and outcomes .
( 2003 ) evaluated the integrated computer system in south africa . in their evaluation , they focused on optimal education , change management and support , project management , improvement of the link systems , maintenance of information confidentiality , standardization of processes to manage patients , increase of revenue and cost of each service package .
uk health informatics institute presents a framework for evaluating health information systems . in this framework ,
a system is considered weak if it does not provide its users with proper information . for the information system to be successful ,
not only the users information needs should be met , but the manner of interaction between the system and its users should also be considered .
in other words , the quality of a system depends on its usability , availability , reliability , adaptability and response time .
the purpose of usability evaluation is to determine the strong and weak points of information systems and to provide guidelines for the improvement of their application .
ergonomic quality of software systems should be evaluated with reference to their application context ( including user , task , equipment and environment ) , user type and users computer experience .
the 17 parts consist of general introduction , general guidance on task requirements , visual display requirements , keyboard requirements , workstation layout and postural requirements , environmental requirements , display requirements with reflection , requirements for displayed colors , requirements for non - keyboard input devices , dialog principals , usability statements , presentation of information , user guidance , menu dialogs , command dialogs , direct manipulation dialogs , and form filing dialogs . and the seven principles are suitability for the task , self - descriptiveness , controllability , conformity with user expectations , error tolerance , suitability for individualizations , and suitability for learning .
isometrics is a reliable and suitable technique for his evaluation [ 15 , 21 ] .
it is a technique to evaluate the usability of software applications with respect to the international standard iso 9241 part 10 .
isometrics is user - oriented . due to the two versions of isometrics evaluation  formative and summative- , two kinds of isometrics  short and long 
it is conducted during the engineering life cycle of the information system or before its further development . in recent years , many researchers have evaluated usability of clinical information systems [ 2226 ] .
the results of the studies conducted on the usability evaluation of health information systems show that little attention has been paid to usability [ 2730 ] .
is - h*med , sap - hr and microsoft word for windows ( version 2.0 ) are the three softwares which were evaluated using isometrics in 1999 , 2000 , and 2004 , respectively [ 15 , 21 ] . the year of evaluation , name , number of users , and application of each software are presented in table  1 . 

table 1software s evaluated by isometricsauthorsyear of evaluationsoftware namenumber of userssoftware s applicationhamborg et al.2004is - h*med182creation of release plan , review of diagnostic and laboratory findings , documentation of diagnostic findings , diagnostic related group ( drg ) , medical examination order , documentation of medical examinations , nursing category , and ordering meals.evaluation done at the university hospital of heidelberg , department of internal medicine.gruber2000sap-hr28support of many tasks in the field of human resource management such as personnel time management , training and event management , and payroll accountinggediga et al.1999microsoft word for windows ( version 2)55winword is a word processing software by microsoft software s evaluated by isometrics in this article , the evaluation results of the three softwares  is - h*med , sap - hr and microsoft word ( version 2.0)are compared with that of iran s his .
in this research used a usability questionnaire based on iso 9241 part 10 so that the usability of hospital information systems could be investigated .
the questionnaire consisted of 75 items based on the seven principles of suitability for the task , self - descriptiveness , controllability , conformity with user expectations , error tolerance , suitability for individualization , and suitability for learning .
table 2the seven principles of iso 9241 part 10suitability for the tasksoftware is suitable , if it supports the user to realize his tasks effectively and efficiently.self-descriptivenesssoftware is self - descriptive , if every step is understandable in an intuitive way , or , in case of mistakes supported by immediate feedback.controllabilitysoftware is controllable , if the user is able to start the sequence and influence its direction as well as speed till he reaches his aim.conformity with user expectationssoftware conforms with the user s expectations , if it is consistent , complying with the characteristics of the user , e.g. taking into account the knowledge of the user in that special working area , accounting education and experience as well as general acknowledged conventions.error tolerancesoftware is error tolerant , if it requires no or just minimal additional effort despite obvious faulty steering or wrong input.suitability for individualizationsoftware is suitable for individualization , if the system allows customizing according to the task as well as regarding the individual capabilities and preferences of a user.suitability for learningsoftware supports the suitability of learning , if the user is accompanied through different states of his learning process and the effort for learning is as little as possible .
the seven principles of iso 9241 part 10 it is to be mentioned that the 75-item questionnaire included 15 questions for suitability for the task , 12 questions for self - descriptiveness , 11 questions for controllability , 8 questions for conformity with user expectations , 15 questions for error tolerance , 6 questions for suitability for individualization , and 8 questions for suitability for learning
. each question of the isometrics questionnaire is assessed on a five - point rating scale starting from 1 (  predominantly disagree  ) to 5 (  predominantly agree  ) .
questionnaires with more than 20% of missing data ( more than 15 unanswered items ) were not analyzed . in case of less than or equal to 15 omissions ,
the missing values were replaced by the mean scale value ( 3 ) of the items .
some items of the questionnaire ( a1 , a8 , t12 , e8 , f1 , f7 , f14 , l1 , and l7 ) were negative in nature .
the values of these items were inverted by the transformation ri  =  6ri for further analysis . for statistical analyses , one - sample t - test and p - values were used .
then , the results of the first stage were compared with those of the three softwares which were evaluated by the same isometrics .
a multi - step sampling was conducted for the first stage of the study ; that is , first the capital s hospitals having computerized hospital information systems were determined .
then a list of companies providing such systems was prepared . and finally , for each company , one hospital was selected .
these companies included rayavaran , tarrahane boo ali , rahavard rayane , data link informatics , teb - o rayane , tirajhe rayane , pouya padideh , kian tak , smart chip . and the hospitals consisted of firoozgar , toos , shariati , rasoul , hashemi nejad , children medical center , kasra , vali - e asr , kashani , day , hazrat - e fatima , atieh , and imam reza .
to conduct the second stage of the study , the his isometrics mean value were compared with those of the three other applications , i.e. , is - h*med , sap - hr , and microsoft word .
is - h*med , sap - hr , and microsoft word were the softwares evaluated using iso 9241 part 10 by hamborg et al . in 2004 , gruber in 2000 , and gediga et al .
the viewpoints of three types of users ( nurses , users of paraclinic units , and department secretaries ) were studied using a standardized isometrics questionnaire . for that purpose ,
one nurse was selected for every ten beds and one user from every paraclinic unit .
however , the viewpoints of all department secretaries were studied . in total , 285 individuals including 98 nurses , 88 department secretaries and 77 users of paraclinic units filled out the standardized isometrics questionnaire .
it is to be mentioned that 22 of the questionnaires were filled out by unidentified user types . 

table 3frequency and percentage of the user typesuser typefrequencypercentagenurses9837.3department secretaries8833.4users of paraclinic units7729.3total285100there were 22 unidentified user types frequency and percentage of the user types there were 22 unidentified user types more than half of the users ( 56.8% ) were nurses .
also , most users ( 62.5% ) had worked for 19  years and 57 users ( 31% ) for 1019  years in their current positions . in addition , most users ( 274 individuals , i.e. , 88.2% ) were female .
moreover , the subjects were mostly ( 119 individuals , i.e. , 43.6% ) in the age group of 3039  years old . furthermore , most of them ( 65.5% ) had a bs degree .
regarding computer literacy , some 66% of users did not have enough computer literacy to use information systems .
however , 178 users ( 62.7% ) declared that their computer literacy was at the average level . among them , only 90 users ( 34.1% ) had the icdl ( international computer driving license ) certificate .
in this study , the viewpoints of three types of users about usability of hospital information systems were considered .
figure  1 shows the users viewpoints regarding the usability of his in iran . 

1his isometrics scale means his isometrics scale means the mean value of his was compared with that of is - h*med , sap - hr , and microsoft word separately , using p - values and t - tests .
figure  1 shows that the value of scale  conformity with user expectations  is higher than the others ; yet , compared with is - h*med , it has a lower value . the comparison between his and is - h*med reveals that his is significantly more usable than is - h*med with respect to all principles except conformity with user expectations .
regarding this principle , the following are among the points to be considered consistently by his designers : predictability of the time needed to perform a task , anticipation of the screen in the following processing sequence , defining the same function keys throughout the program for the same functions , emergence of messages in the same location . as mentioned earlier , is - h*med , sap - hr , and microsoft word for windows , version 2 were evaluated by hamborg et al . , gruber , and gediga et al .
the isometrics mean value of his ( evaluated by the present researchers ) is compared with that of the other three evaluations in terms of t , df ( degree of freedom ) , p value and d. 
 table 4comparison between his and is - h*medisometrics scalemeantdfpdis - h*medhissuitability for the task2.773.042.55284<0.0000.27self - descriptiveness2.682.864.38284<0.0010.18controllability2.973.093.002840.0030.12conformity with user expectations3.063.141.842840.0650.08error tolerance2.852.952.802840.0050.109suitability for individualization2.122.577.78284<0.0010.45suitability for learning2.842.973.17284.00020.13table 5comparison between his and sap - hrisometrics scalemeantdfpdsap - hrhissuitability for the task2.303.0420.35284<0.0010.74self - descriptiveness2.822.861.042840.2980.004controllability3.573.0910.51284<0.0010.44conformity with user expectations3.213.141.292840.1950.06error tolerance2.822.953.57284<0.0010.13suitability for individualization2.592.570.3132840.7550.01suitability for learning2.672.977.32284<0.0010.30table 6comparison between his and microsoft word ( version 2.0)isometrics scalemeantdfpdmicrosoft wordhissuitability for the task3.843.0421.59284<0.0010.79self - descriptiveness3.982.8626.62284<0.0011.11controllability3.923.0919.51284<0.0010.82conformity with user expectations3.753.1412.65284<0.0010.60error tolerance3.632.9517.14284<0.0010.67suitability for individualization3.642.5718.39284<0.0011.06suitability for learning3.742.9718.772840.0010.76 comparison between his and is - h*med comparison between his and sap - hr comparison between his and microsoft word ( version 2.0 ) according to table  5 , his is significantly more usable on scales of suitability for the task , error tolerance , and suitability for learning . as it can be seen in table  6 , usability of his
in fact , his does not meet the ergonomic quality of a standard windows application .
figure  2 shows the isometrics scale means of his , is - h*med , sap - hr and microsoft word ( version 2.0 ) .
figure  2 and tables  4 and 5 show that the usability of his is rated higher than that of is - h*med and sap - hr , from the users point of view . however , the word processing software is more usable than all these .
in other words , from the users point of view , microsoft word meets the ergonomic quality more . 

2isometrics scale means of his , and is - h*med , sap - hr and microsoft word ( version 2.0 ) isometrics scale means of his , and is - h*med , sap - hr and microsoft word ( version 2.0 )
isometrics is a reliable and suitable technique for his evaluation [ 15 , 21 ] .
it is a technique to evaluate the usability of software applications with respect to the international standard iso 9241 part 10 . in this research
the comparison between his and is - h*med showed that the former was significantly rated higher than the latter on all isometrics scales except 
therefore , it is suggested that hospital information system designers pay more attention to the following points : 
 predictability of the time needed to perform a taskanticipation of the screen in the following processing sequencedefining the same function keys throughout the program for the same functionsemergence of messages in the same location predictability of the time needed to perform a task anticipation of the screen in the following processing sequence defining the same function keys throughout the program for the same functions emergence of messages in the same location the scale mean of suitability for the task in his is 3.04 .
it seems that his designers do pay attention to the suitability of his for the task , but apparently this much attention is not enough .
many research results have shown that inattention to the scale  suitability for the task  increases the amount of error , which will in turn have a negative impact on tasks [ 22 , 24 , 32 ] . regarding the principle 
, one of the questions asked whether the software helped the users to perform their task . in response to the above question
, 23.9% of the subjects of the present study believed that the his did not help them with performing their task ; rather , they believed that it acted as an obstacle .
moreover , in a study as  a usability evaluation of four commercial dental computer - based patient record systems  conducted by thyvalikakath et al .
( 2008 ) , it was shown that 28% of users failed to perform their duties when using the system . in their study ,
they pointed out that it was necessary to do more studies about documentation errors while using the hospital information system .
many studies also revealed that a decrease in the his usability led to an increase in the errors committed in performing the task [ 22 , 24 , 33 , 34 ] .
the mean of  suitability for learning  in his was rather low ( 2.98 ) .
however , in a study done by thyvalikakath et al . on dental computer - based patient record system ,
therefore , it is suggested that the country s his designers pay more attention to 
the results show that hospital information system in iran is average in terms ergonomic quality .
it is to be mentioned that the ergonomic quality of an information system should be determined with regard to its context .
that is why , in the present study , this quality was evaluated with regard to the user types ( nurses , users of paraclinic units , and department secretaries ) .
this study was done based on isometrics short which has certain weaknesses ; i.e. , the cause of users dissatisfaction and of the problems existing in the information system can not be determined . to discover the cause of such problems and weak points , isometrics long   is needed .
in addition to this type of isometrics , such techniques as user tests   and walkthroughs   can also be used .
walkthrough is the superficial examination of a computer program before running it by reading the source code ( program instructions ) .
walkthrough aims at identifying the possible errors in the initial stages of information system development .
when we had received the evaluator reports we began the user tests , hoping to detect more possible problems in the use of terminology databases and at the same time compare the results the expert evaluation with the observations of the users .
one of the important things is that the evaluators must pay attention to the number of users .
cohan ( 1988 ) found out that the number of users was a factor affecting the results . in this research study , the viewpoints of 285 users were considered while gruber   and gediga   studied the viewpoints of only 28 and 55 users in their studies , respectively .
it should be noted that the evaluation of information systems is a complex process because all human , technical and organizational aspects should be considered .
 evaluation of iran s his ( hospital information system ) ergonomic quality using isometric 9241 part 10 and compared results of that evaluation with results of ergonomic quality evaluation other softwares which evaluated by isometric 9241 part 10 . 
 this research study was conducted in two stages . in the first stage , 
 the researchers evaluated the his of 13 hospitals in iran using iso 9241 part 10 , and in the second stage , they compared the evaluation results with the following softwares : a ) is - h*med ( evaluated by hamborg et al . 2004 ) b ) sap - hr ( evaluated by gruber 2000 ) c ) microsoft word for windows , version 2 ( evaluated by gediga et al . 1999 ) . for first stage 
 used usability questionnaire called isometrics which is based on the international standard iso 9241 part 10 . 
 this questionnaire is including 75 items based on the seven principles . 
 data analyzed using spss and excel . the comparison between his and is - h*med 
 reveal that the former is significantly more usable than the latter in terms of all isometrics sales . 
 the his also proved to be significantly more applicable than sap - hr in terms of such isometrics scales as  suitability for task ,   suitability for learning  ,  error tolerance  and  learning ability  . 
 however , his was found to be significantly less usable than microsoft word . 
 the results of the study show that compared with the mentioned three softwares , iran s hospital information system enjoys an average ergonomic quality . 
 therefore , it is recommended that the users comments and expectations be considered more when information systems are designed and developed . 
Introduction
Materials and methods
Results
Conclusions