Document(s) 6 de 31

Introduction

Decision making in public health depends on the availability of reliable information, which is generated, analyzed and disseminated by information systems.^1,2 However, most national health information systems lack the information needed to address health inequities, namely, reliable, longitudinal data that links measures of health with measures of social status at the individual or small-area level.

At all levels of health care, particularly in primary care, there is a consensus concerning the usefulness of information technology, especially for promoting greater efficiency in management processes.^3,4 Although studies evaluating the impact of such technologies on health are still rare,^5,6 most authors agree that there are positive effects from these systems and that they can be improved further through regular monitoring.

Low levels of computerization in primary health care are very common. Furthermore, many papers stress the need for continued motivation and training for all team members as a prerequisite for the success of any initiative in this area.^7,8 It may be pertinent here to quote the reflections by Branco⁹ on the significance of training, that is, the amplification of knowledge:

… knowledge of the logic behind health information production and flux must be provided to all persons involved, and should include an understanding of the goals of the systems to which they have access, and of the possibilities for use of the information produced …

Martinez et al¹⁰ analyzed communication and information needs in primary health care in rural areas from Peru and Nicaragua. They found three main factors related to the inefficiency of the health systems: poor infrastructure, a lack of information systems and deficiencies in the training of health professionals. Other authors have emphasized the need to incorporate good-quality health care data from local levels into national databases.^11–14 Similarly, Gething et al¹⁵ stated that the value of information systems in health is to point out the needs and priorities at both national and local levels, but the process of feeding data into the systems often fails.

Another source of problems is the contrast between the availability of information technology (IT) at the central level of health system management and its shortage elsewhere, particularly in primary care. There is often pressure for new data, increasing the time required for collection, with no assurance about its analysis, dissemination and usefulness in decision making. The great quantity of data about each patient, recorded by health professionals, seems to have little meaning in their daily activities.¹⁶ We believe that all of these factors contribute to the current situation – but especially the lack of motivation of most health care staff and the poor integration between health care and IT professionals.

Establishing IT in the health services, especially in primary care, is a challenge for the advance of information systems, not only in the smaller and poorer towns. In bigger cities, the central levels of the health system generally have good access to IT resources, but the recording of the actions of the major part of the health services is still performed manually.¹⁶

There are few reports in the literature about the experience with the development and use of computerized systems in primary care. Herman et al¹⁷ described the Community Health Information Tracking System (CHITS) in the Philippines, which has the objective of integrating local and national level information and pointing out ‘islands’ in the information systems and a great amount of repeated work in the management of such systems (see also Chapter 3). Aspects related to access to data from different information systems, and their use and control, should be considered, including their creation, implementation, monitoring and evaluation.¹⁸

IT in primary care in Brazil

Two recent initiatives from the Brazilian government are the National Information Policy on Informatics in Health (NIPIH/PNIIS)¹⁹ and the National Telemedicine Programme in 2006.²⁰ The NIPIH focuses on health work, on the user and on the electronic health record. The proposals are underpinned by standards to represent and share health information, the connectivity structure, the training of human resources in the information systems in health, and, above all, the guarantee of privacy and confidentiality of the information.

National Telemedicine Programme

Telemedicine activity currently involves about 30 universities and research institutes in 9 of the 27 Brazilian states. The pilot project in telemedicine for primary care involves the installation of 900 PCs, mainly for decision support. These PCs are connected to a wide area network, and can also be used for videoconferencing. They have an electronic medical record, which can be shared with other units. Priority is being given to cities where there is a family health programme, a population of less than 100 000 and geographical barriers to health care. The Ministry of Health, together with the Ministry of Education, has been investing in distance learning for training and continuing education of health professionals.

National information systems

The information systems available in Brazil consist of large databases of statistics. These include births, deaths and a disease surveillance system. There are also tools for the management of outpatient and hospital services.

The only computerized health information system used in family health centres is the Primary Care Information System. This is the source of information, and provides most of the tools and the forms completed by the primary care team. Most health professionals recognize it as a tool for improving the epidemiological profile, but it is underutilized. According to the staff concerned, this underutilization is due to various limitations of the system, to a lack of knowledge and lack of preparation for exploring its full capacity, to a lack of training and to a lack of incentive to use it for data analysis. The system has weaknesses, but some professionals also have difficulties in manipulating it both regarding the input of data and in producing reports.

Data collection is fragmented, with no connection with health policies to facilitate the planning and decision making. The data collection and transfer mechanisms generate repeated work and reduce efficiency in the management of information.¹⁹ The system does not allow integration with other systems, and cannot identify users and show their links to health services. For this, a National Health Card is being implemented. However, because of the magnitude of the investment required, progress has been slow.

The proliferation of information systems should be highlighted. For each need, sector, disease or event, new software is created, implying high costs for development and maintenance, and a lack of standardization and interoperability. According to Cohn et al,¹² there is little use of information from the large databases in Brazil, especially in small towns. The full potential of the information has yet to be realized.^12,21

Telemedicine

Separate from the National Telemedicine Programme, the BH Telemedicine Project was implemented in 2003. The aim was to promote the continuing education of health workers in primary care units, as well as contributing to the modernization of the public health system. The BH Telemedicine network connects primary care centres to the Federal University of Minas Gerais teaching units, with activities in the fields of medicine, nursing and dentistry. The network uses videoconferences for continuing education, and teleconsulting between specialists and staff at the primary care centres for second opinions and for discussion of clinical cases. The videoconferencing network operates at 128 kbit/s.

The telemedicine network has been implemented in 121 primary care centres. About 1500 teleconsultations per year occur between specialists and staff at the primary care centres. In 2006, there were 75 educational videoconferences, including medical, nursing and dentistry areas, involving more than 5000 participants. The activities have resulted in more effective participation of the oral health group, followed by nurses and finally by the physicians.

The project has been evaluated by two groups. The results showed better outcomes for the cases discussed, with about 70% of patients staying in basic units, with no need for referral to a specialist. There was also a reduction of 71% in the number of patients who needed to travel to the Clinics Hospital of Belo Horizonte to be seen.

Computerized tools

In 2005, a survey was conducted to characterize primary care and evaluate differences in the effectiveness of services according to the model of care – family health or traditional.¹⁶ Under the Family Health Programmes (FHP), teams are composed of a doctor, a nurse, a nurse technician and about five community health agents. These teams are responsible for supervising a set number of families (about 1000) living in a particular area. The teams undertake work involving health promotion, prevention, recovery and rehabilitation. In the traditional model, teams do not include community health agents and do not have their activities focused on health promotion and disease prevention.

The survey enrolled 41 municipalities of more than 100 000 inhabitants in the south and north-east regions of Brazil, which represented approximately 20% of these size municipalities in the country. There were systematic differences between the demographic and socioeconomic indicators from the south and north-east of the country. In the south, the average human development index (HDI), life expectancy, number of literate people and homes with tap water supply were higher than in the north-east. North-east municipalities showed a higher proportion of poor people (41% vs 17%), while the southern municipalities showed a higher proportion of elderly citizens (9% vs 7%).

Information about the 236 primary care centres was obtained by questionnaire: 4749 health workers were studied. Among these, 11% were physicians, 7% nurses, 8% professionals with another college degree, 18% nursing assistants, 23% other professionals with a high school degree and 33% community health agents. One-third of the primary care centres had a computer (35%): 40% in the south and 29% in the north-east. Considering the care model, 39% of the family health services had a computer, as opposed to only 25% of the traditional services (Table 4.1). Only 11% of the primary care centres had Internet access: 17% in the south region and 5% in the northeast region. The traditional services had more Internet access (14%) than the family health services (9%) (Table 4.2).

About 20% of the health workers mentioned their use of computers for professional activities. This use was almost 50% among physicians, nurses and other professionals with a college degree, and a little more than 10% among nursing technicians, community health agents and other members of the teams who had a high school education. The use of computers in the primary care centres was even less frequent, being mentioned only by 8% of the professionals (Table 4.3).

Depending upon the region, the use of computers in health centres was 14% in the south and 5% in the north-east. Depending upon the care model, it was 10% in family health services and 6% in the traditional centres (Table 4.4).

PACOTAPS

PACOTAPS is a tool for decision making. The objective of the PACOTAPS software is to assist health managers and teams with information about population characteristics and health demands.²² The software provides a structure to receive data about the contacts and procedures performed at primary care centres. The origin document is the Outpatient Contact Form, which is completed by the health team and signed by the user. Once the form has been completed, the data are typed in using a module called users contact with the services.

PACOTAPS includes lists of professionals, groups and procedures that are standardized by the Outpatient Information System. For the identification of the diagnosis, PACOTAPS provides the application PESQCID,²³ which allows a guided consultancy to the International Classification of Diseases (ICD-10).²⁴ Thus, using the system it is possible to find out, for a certain period of time, the distribution of patients by age and gender, the main diagnosis and the proportion of referrals.

Training

About 400 primary care workers from the 41 cities under study were trained in monitoring and evaluation through practice exercises in a computer laboratory, in two regional workshops. The participants could install, become familiar with and use PACOTAPS, with emphasis on the module users contact with the services. Thus, they were able to understand its usefulness for the daily activities of primary care centres, and in municipal health management. The simplified data entry and the immediate availability of reports were very attractive, as these are requirements often mentioned by health workers. The training aims to make health workers aware of the need to produce accurate and valid information. At the end of training, each municipality received a CD for installation of the software and the application manual.

Survey results

In the PROESF study, all the 26 019 user contacts with the primary care centres were recorded in PACOTAPS. Information was collected about the users’ profiles (age, gender and health problems), the procedures performed and the referrals. One-third of the contacts (35%) were for women between 15 and 49 years old, i.e. of reproductive age. The second largest group was for people 60 years of age or older (19%) and the third largest group was children below 5 years old (15%).

Every user can receive one or more procedures at each contact. For example, a child may receive an immunization and also have a medical consultation for diarrhoea; an elderly person may have his or her blood pressure checked, have a medical consultation for back pain and receive his or her medication; a pregnant woman may have her weight checked, have a medical consultation for urinary infection and be attended to by the social worker for receiving a benefit. Therefore, the number of procedures is usually higher than the number of people attended to. In this sample, more than 37 000 procedures were analysed.

Although nurses and nurses’ assistants comprised 25% of the teams, they performed more than half of the procedures (53%). The physicians, who represented 11% of the professionals, accounted for 26% of the procedures. Almost 70% of the procedures were related to factors that influenced the health status and the contact with the services, such as prenatal care and paediatrics, immunization and screening tests. After this, health problems related to the digestive system (7%), circulatory system (4%) and respiratory system (4%) were observed more frequently.

Although 23% of the records did not have information about referrals, it was observed that in 70% of the contacts there was no need to refer the user to other care levels or to request diagnostic tests.

Conclusions

Primary care plays a major role in producing better health care for all people, particularly in developing countries. Efforts are now being directed towards the improvement of different models of care. As in other places, in Brazil, family health care is becoming a successful equity promotion effort, because it is more widely present in poorer regions with a more vulnerable population. Despite limitations that are common to primary care, the family health programme does more for whoever needs more.

The experience of the BH Telemedicine implementation provides guidance for the future:

• potential for innovation in the public network
  
  
• standards governing the interaction between teaching and the assisting practice of the health services
  
  
• improvements in the assisting structure, with possibilities of reduced costs and better structuring of a multidisciplinary project of telemedicine.

The main challenges regarding IT for primary care are:

1. To improve IT in primary care centres, rather than at the central levels of health system management.
   
   
2. To estimate standardization and compatibility between national health information systems, especially through web-based tools rather than the production of local software or information systems.
   
   
3. To promote a wide professional training in IT as a strategy to facilitate its use in decision making for clinical practice, and to monitor and evaluate health programmes, focusing on people rather than on technology.

Overall, this will require greater investment in IT and telecommunications directed towards the basic health units. This investment should be made by municipalities, but currently there are other priorities in the country’s public health system, and resources are scarce.

Further reading

Araújo Novaes M, Pinto Barbosa AK, Soares de Araújo K et al. Experiences on the use of a second opinion software for the primary care. AMIA Annu Symp Proc 2005: 889.

Edworthy SM. Telemedicine in developing countries. BMJ 2001; 323: 524–5.

Goodman KW. Ethics and health informatics: focus on Latin America and the Caribbean. Acta Bioeth 2005; 11: 121–6. Available at: www.scielo.cl/scielo.php?pid=S1726-569X2005000200002&script=sci_arttext&tlng=en.

Hira AY, Lopes TT, de Mello AN et al. Establishment of the Brazilian Telemedicine network for paediatric oncology. J Telemed Telecare 2005; 11(Suppl 2): 51–2.

Rigby M. Impact of telemedicine must be defined in developing countries. BMJ 2002; 324: 47–8.

References

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⁵ Macinko J, Guanais FC. Selected Annotated Bibliography on Primary Health Care in the Americas. Pan American Health Organization’s Primary Health Care Working Group, 2004. Available at: www.opas.org.br/servico/arquivos/Sala5520.pdf.

⁶ Mitchell E, Sullivan F. A descriptive feast but an evaluative famine: systematic review of published articles on primary care computing during 1980–97. BMJ 2001; 322: 279–82.

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¹⁰ Martinez A, Villarroel V, Seoane J, del Pozo F. Analysis of information and communication needs in rural primary health care in developing countries. IEEE Trans Inf Technol Biomed 2005; 9: 66–72.

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¹⁵ Gething PW, Noor AM, Gikandi PW et al. Improving imperfect data from health management information systems in Africa using space–time geostatistics. PLoS Med 2006; 3: e271.

¹⁶ Facchini LA, Piccini RX, Tomasi E et al. Monitoramento e avaliação do Projeto de Expansão e Consolidação da Saúde da Família: relatório final. Pelotas: UFPel, 2006. Available at: www.epidemio-ufpel.org.br/proesf/index.htm.

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²⁰ Brasil, Ministério da Saúde. Portaria n° 35 de 4 de janeiro de 2007 que institui, no âmbito do Ministério da Saúde, o Programa Nacional de Telessaúde. Brasília: MS, 2007. Available at: dtr2004.saude.gov.br/dab/docs/legislacao/portaria35_04_01_07.pdf.

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