Journal of health research in community

Introduction
The overall objective of this research is to design a conceptual model of hospital information system (HIS) indicators using the logic model. In line with this objective, four specific objectives are pursued: (a) identify and explain HIS evaluation indicators by reviewing the literature, (b) to extract structural indicators related to the HIS evaluation from the perspective of experts, (c) to identify evaluation process indicators that indicate the performance and efficiency of the HIS in practice, and (d) to define the indicators that examine the outcomes and outputs of the HIS performance from the perspective of stakeholders. These goals generally seek to provide a comprehensive and reliable model for evaluating and improving the efficiency of HISs, thereby enabling more effective data management and health decision-making.

Materials & Methods
This qualitative study using the Graneheim and Lundman’s content analysis method. The study population included senior, middle, and operational managers of selected general hospitals affiliated with Mazandaran University of Medical Sciences and Babol University of Medical Sciences (Hazrat-e Zahra, Rouhani, and Shahid Rajaee hospitals), experienced accreditation assessors with at least five years of experience, as well as professors and PhD graduates in health information management and health policymaking. Participants were selected purposively with the snowball approach. Data were collected through semi-structured interviews, using questions designed based on the literature review and expert comments.
Data analysis included full transcription of interviews, identification of semantic units (words, sentences, and paragraphs), coding, and grouping them into more abstract categories and themes. Guba and Lincoln’s criteria were used for assessing the trustworthiness of the data by using long-term participation, peer review, participant feedback, and faculty approval. After analysis, the findings were presented to an expert panel and reviewed in two rounds based on the Delphi method. In this stage, the indicators were rated on a 9-point Likert scale. Those with a mean score below 4 were eliminated, those with a score above 7 were accepted, and those with a score between 4 and 7 were re-assessed in the second round. Final consensus was reached when the change in mean scores between the two rounds was less than 15%, and the response rate was greater than 70%. Each interview lasted an average of 45 minutes.

Results
In this qualitative study, the opinions of 20 experts were used; 55% were female and 45% were male. In terms of education, 25% had a PhD degree, 35% a master’s degree, and 40% a bachelor’s degree. By reviewing the literature and conducting semi-structured interviews, 777 indicators were initially identified, which were reduced to 471 by removing duplicates and overlapping items. Finally, 407 final indicators were selected. These indicators were divided into four categories based on the logic model: structural (n=100), processes (n=101), outputs (n=95), and outcomes (n=111). Eight main themes were also extracted, including management & leadership, administration & support, facilities & equipment, productivity, paraclinical, clinical, financial, and environmental.
In the domain of management & leadership, experts indicated the challenges such as practical training, time constraints for patient education, weakness in root cause analysis of errors, and incomplete implementation of the analysis of states and errors in documentation and information systems.  
In the domain of administration & support, issues such as shortage of manpower, need for improved training, occupational safety, issues related to water quality, water treatment plant, and hospital waste, shortage of personal protective equipment, and waste management problems were raised. 
In the domain of ​​facilities & equipment, problems such as lack of specialized equipment, delays in repairs, and financial constraints were identified.  In the theme of productivity, the main factors were optimal use of hospital beds, reducing length of stay, managing admission and discharge processes, and fair distribution of human resources. In the paraclinical domain, the challenges of staff shortages, drug shortages, increased demand for diagnostic services, and delays in reporting test results were identified as key issues. In the clinical domain, reducing mortality, managing medication errors, improving critical care, and improving patient safety were among the most important indicators. In the financial domain, cost management, insurance deductible control, resource allocation, and increasing revenue by improving service quality were key issues. Finally, environmental indicators included energy consumption, waste management, paper consumption, and the use of energy-efficient equipment as factors for sustainable development.

Conclusion
In this study, 407 indicators were identified for HIS evaluation and categorized into eight main themes: leadership & management, administration & support, facilities & equipment, productivity, paraclinical services, clinical services, finance, and environmental indicators. Based on the logic model, they were classified into structural, process, output, and outcome levels. Structural indicators reflected resource capacity; process indicators captured operational performance, and outcome indicators highlighted service quality and long-term health effects. The study recommends strengthening infrastructure, improving clinical and paraclinical workflows, and validating the model through quantitative methods in future studies.

Ethical Considerations
Compliance with ethical guidelines
All ethical considerations, including informed consent, data confidentiality, and participant autonomy, were observed. The study was approved by the Ethics Committee of Mazandaran University of Medical Sciences (Code: IR.MAZUMS.REC.1402.295).

Funding
This article was extracted from Seyyede Tayebeh Mansori’s master’s thesis in Health Services Management at Mazandaran University of Medical Sciences.  This research did not receive any specific grant from funding agencies in the public, commercial, or not-for profit sectors.

Authors contributions
Ghasem Abedi and Roya Malekzadeh contributed to the study design; Seyyede Tayebeh Mansori contributed to data collection; Seyyede Tayebeh and Roya Malekzadeh contributed to data analysis, writing, review & editing.

Conflicts of interest
The authors declare no conflicts of interest.

Acknowledgements
The authors would like to thank all participants for their cooperation in this study.


References

1. Amiresmaili M, Zarei L, Sheibani E, Arabpur A. [Evaluation of the indicators of hospital information system (Persia)]. Health Inf Manage 2013; 10(1):3-15. [Link]
2. Thanos L, Gallos P, Zoulias E, Mantas J. Investigating the success of "asklepieio voulas" hospital information system. In: Mantas J, Stoicu-Tivadar L, Chronaki C, Hasman A, Weber P, Gallos P, et al, editors. Public health and informatics. Amsterdam: IOS Press; 2021. [DOI:10.3233/SHTI210245]
3. Naderi Manesh K, Nasiripour A, Masoudi Asl S, Babouei A, Ostovar R, Rezanjad M. [The study of the status of performance indicators in selected educational and non-educational hospitals of tehran province (Persian)]. Armaghane Danesh. 2020; 25(1):104-17. [DOI:10.52547/armaghanj.25.1.104]
4. Meraji M, Mirzaee S, Taghizade E, Monazah F. Comparing emergency department performance indicators in trauma centers. 2019. J Health Adm. 2019; 22(3):67-78. [Link]
5. Moghadamnia A, Jahani M, Bijani A, Yaminfirooz M, Naghshineh A, Mohammadnia K. [Evaluation of performance indicators and frequency of patient referrals in the hospitals affiliated to Babol University of Medical Sciences in 2013 (Persian)]. J Babol Univ Med Sci. 2016; 18(5):61-9. [DOI:10.22088/jbums.18.5.61]
6. Reisi-Nafchy M, Drees F, Mirzaeian R R. [Assessment of performance indicators in Hospitals University of Medical Sciences based on the standards of the Ministry of Health (Persian)]. J Shahrekord Univ Med Sci. 2014; 15(6):60-7. [Link]
7. Dehghani M, Rahimi B, Makhdomi K, Jebraeily M. [Determining key performance indicators in dialysis management dashboard for monitoring service quality (Persian)]. J Mod Med Inf Sci. 2023; 9(1):46-55. [DOI:10.32598/JMIS.9.1.8]
8. Jahanbakhsh M, Raeisi AR, Javaheri Kian E. [Identification of hospital information system performance key indicators for benchmarking; A qualitative study (Persian)]. Manage Strateg Health Syst. 2018; 3(1):17-32. [Link]
9. Tofighi S, Fallah M, Khajeh Azad M. [Quality evaluation of knowledge management in a military hospital based on the Baldrige excellence model (Persian)]. J Mil Med. 2012; 13(4):213-6. [Link]
10. Raadabadi M, Mobaraki H, Nazari A, Bakhteyari M. Investigations the functional indicators change due to implementation information system in Sina hospital. J Shahrekord Univ Med Sci. 2013; 15(5):90-6. [Link]
11. Asadi H, Soola AH, Hamidi R, Rezapour A, Ershadifard S, Davari M. [Performance indicators of hospitals affiliated to Ardabil University of Medical Sciences in 2019 (Persian)]. J Iran Inst Health Sci Res. 2021; 20(3):285-93. [DOI:10.52547/payesh.20.3.285]
12. Malekzadeh R, Mahmoodi G, Abedi G. [Assessment of hospital performance using balanced scorecard model and program chain pattern (Persian)]. J Health Promot Manage. 2019; 8(3):53-8. [Link]
13. Zolfaghari Z, Rezayatmand M, Alizadeh M, Saghaeiannejad S. Profiles for the key performance indicators (KPIs) of the hospital financial information system. J Health Adm. 2025; 28(1):95-108. [DOI:10.61882/jha.28.1.95]
14. Anema HA, Kievit J, Fischer C, Steyerberg EW, Klazinga NS. Influences of hospital information systems, indicator data collection and computation on reported Dutch hospital performance indicator scores. BMC Health Serv Res. 2013; 13:212. [DOI:10.1186/1472-6963-13-212] [PMID] 
15. Hofer TP, Bernstein SJ, Hayward RA, DeMonner S. Validating quality indicators for hospital care. Jt Comm J Qual Improv. 1997; 23(9):455-67. [DOI:10.1016/S1070-3241(16)30332-7] [PMID]
16. Aloh HE, Onwujekwe OE, Aloh OG, Nweke CJ. Is bed turnover rate a good metric for hospital scale efficiency? A measure of resource utilization rate for hospitals in Southeast Nigeria. Cost Eff Resour Alloc. 2020; 18:21. [DOI:10.1186/s12962-020-00216-w] [PMID] 
17. Mayelafshar M, Noohi F, Riahi L, Nikravan A. [Key performance indicators of emergency department: A literature review (Persian)]. Iran J Cardiovasc Nurs. 2019; 8(1):10-9. [Link]
18. Schmaltz SP, Williams SC, Chassin MR, Loeb JM, Wachter RM. Hospital performance trends on national quality measures and the association with Joint Commission accreditation. J Hosp Med. 2011; 6(8):454-61. [DOI:10.1002/jhm.905] [PMID] 
19. Nippak PM, Veracion JI, Muia M, Ikeda-Douglas CJ, Isaac WW. Designing and evaluating a balanced scorecard for a health information management department in a Canadian urban non-teaching hospital. Health Inf J. 2016; 22(2):120-39. [DOI:10.1177/1460458214537005] [PMID]
20. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004; 24(2):105-12. [DOI:10.1016/j.nedt.2003.10.001] [PMID]
21. Guba EG, Lincoln YS. Competing paradigms in qualitative research. In: Denzin NK, Lincoln YS, Giardina MD, Cannella GS, editors. Handbook of qualitative research. Los Angeles: Sage; 1994. [Link]
22. Reddy CO, Kamath R, Joseph Nazareth JJ, Lakshmi V, Kamath S. [Analysis of quality indicators in operation theatres and intensive care units in a tertiary care hospital in South India (Persian)]. J Health Adm. 2023; 26(2):66-83. [DOI:10.22034/26.2.66]
23. Vafaee-najar A, Ebrahimipour H, Houshmand E, Zomorrodi-Niat H. [Identification and prioritization of hospital performance evaluation indices by combination of balanced scorecard and Delphi (Montaserieh Hospital) (Persian)]. Navid No. 2018; 21(66):1-11. [DOI:10.22038/nnj.2018.31272.1122]
24. Azar A, Mohammadi Y. Developing a mathematical model for hospitals performance evaluation: An hybrid approach of FHNBSC, SAW and LINMAP. J Health Syst Res. 2014; 10(3):509-24. [Link]

25. Mahmoodi A, Taji M, Ayask FA. Evaluating the performance of inpatient wards in hospitals affiliated with Birjand University of Medical Sciences using the pabon-lasso model in the years before and during the COVID-19 pandemic. J Manage Strateg Health Syst. 2023; 8(2):116-29. [DOI:10.18502/mshsj.v8i2.13649]
26. Ghazizadeh J, Partovi Y, Alidoost S, Kavakebi N. [Performance indicators of hospitals affiliated to Health Network in East Azerbaijan before and after health reform (Persian)]. Payesh. 2018; 17(3):217-26. [Link]
27. Dadgar R, Mahmoudi G. [The impact of health system reform plan on the hospital's performance indicators of Lorestan University of Medical Sciences (Persian)]. Yafte. 2017; 19(2):93-102. [Link]
28. Zaheri MM, Zarei MR, Sate FS, Hashemi SS. Comparison of the performance indicators of the Emergency Department of Qom Shahid Beheshti Hospital before and after the Health Transformation Plan,(Iran). Qom Univf Med Sci J. 2019; 13(10):19-25. [DOI:10.29252/qums.13.10.19]
29. Rezaee M, Shahbazifard M, Omranikhoo H. [Financial Indicators of public autonomous hospitals: A case study in Bushehr province in 2021 (Persian)]. Iran South Med J. 2023; 26(2):114-26. [DOI:10.61186/ismj.26.2.114]
30. Mazdaki A, Rezapour A, Khalilabad TH, Mohamadkhani N. [Factors affecting financial indicators in selected hospitals affiliated to Iran University of Medical Sciences before and after health system reform plan (Persian)]. J Health Adm. 2019. 2019; 22(1):40-8. [Link]