Incorporation of Information Technology in Primary Care of Sus

891 free themes DOI: 10.1590/1413-81232015213.01062015 ------The incorporation of information tech 3 firmed at the location the SCNS had beenwhere labor organization, IT can improve incorporated. of the flow data and information and the enable “light” digitalThe insertion of the professional. technology be expedited cannot of health care by as it is necessary impart to the knowledge to IT, working it can improve However, professionals. conditions data gathering by and organization, giving re feedback immediate the professional to and enhancedata the the ability cording man to health policies.age technology Information in health, words Kew Labor card, SCNS of health, in IT Incorporation in health process ry health care of the Unified Health SystemHealth (SUS) ry of the Unified health care with the implementation Health of the National qualitative re involved It System (SCNS). Card withsearch 50 interviews and 96 questionnaires comparing of the opinion health professionals technologicalabout innovation in locations with yetthe SCNS and where it has not been incor Aracaju, and in the cities Pessoa porated of João The expectation IT would that was respectively. speed which the work up conschedule, not was Abstract Abstract nology (IT) via of health data an electronic record in primary is transforming care the organization The in Brazil. practices of labor and professional scope the expectations establish is to of this study experiencesand of incorporatingprimathe in IT Incorporation of information technologyPrimary in of Care SUS expectationsin North-eastern Brazil: experiences and

2 1 Instituto de Saúde Coletiva, Coletiva, Saúde de Instituto Hospital Universitário de de Universitário Hospital Superintendência Superintendência 2 3 1 Universidade Federal da Federal Universidade Brasil. BA Salvador Bahia. Brasília, Universidade de de Universidade Brasília, Brasília DF Brasil. Brasília. Regional Norte/Centro Norte/Centro Regional SEPS 712\912. INSS. Oeste, Bloco Edifício Pasteur. CEP Sul. Asa sala 111. I, Brasília DF Brasil. 70390125. [email protected] Marília Gava Gava Marília Lisiane Seguti Ferreira Eduardo Luiz Andrade Mota Mota Andrade Luiz Eduardo Dario Palhares Dario Palhares 892 Gava M et al. Gava Introduction ing the relatively more elevated management hi- erarchical levels6. When data is consolidated at The Brazilian public health system, or Sistema the management level in townships, states, and único de saúde (SUS) as it is better known, is a ultimately, the Health Ministry, it is converted nationwide exercise of immense dimensions, to organized information which unfortunately, covering as it does, over two hundred million rarely returns to the concerned professionals, Brazilians by providing services of vigilance, thus distancing them from the nature of issues medication, and organ transplantation, to name addressed, as well as mode of action. a few. Barring 24.7% of the population, which is The pilot project of the National Health Card covered by private health insurance1, more than System (SCNS or Sistema Cartão de Saúde), also 150 million Brazilians depend on SUS as the only referred to as Cartão SUS7, was launched by the source of health attention. The magnitude of the Ministry of Health, in order to provide a one-way annual services provided is considerably impres- identification procedure for users, professionals sive: over 2 billion outpatient care procedures, 11 and health facilities of the SUS. The project in- millions hospital admissions and in-patient care, volved hiring of companies for creating specific two hundred thousand cardiac surgeries, and one tools to enable registration of essential categories hundred fifty thousand vaccinations2. of data in health through service terminals of the Efficient management of such a complex SUS (known as TAS or Terminal de Atendimen- and extensive system requires the support of to do SUS), a step that was necessary to feed the informatics and information technology, and is information systems of SUS directly from the one of the biggest challenges facing the hospital end-user. It must be emphasized here that this management personnel, healthcare professionals project did not aim to be merely a simple elec- and informatics experts alike, both in terms of tronic record of clinical data, which would just procedural design, as well as accessibility to the be a documentation of the patient’s detailed case concerned people. history, being made available throughout the The purpose of promoting the innovative, healthcare network. creative and transformative aspects of technolo- The newly designed SCNS has the advantage gy by Brazil’s National Policy of Information and of knowing every user of the SUS, and manag- Informatics in Health3, is to improve healthcare ing patient care across all its health care services, routines, and construct a well-articulated Na- carried out by the diverse entities of health. This tional System of Health Information that can novel approach provides visibility of essential generate and provide knowledge and informa- data for feeding into the information systems. Vi- tion to citizens, managers, and professional prac- tal information thus permeates every moment of titioners, and additionally, exert social control management, of social interaction involved in the over the Health System. trinomial process pf health-disease-care, and the Traditionally, SUS develops health informa- diffusion of results that gives feedback about the tion system procedures to suit the requirements decisions taken and treatment being followed8. of management practices, monitor health situ- It is expected that computerization of the en- ations, control productivity and transfer funds tire procedure will (i) improve the quality of reg- from actions and events. Also taken into consid- isters; (ii) ease usage of feedback information by eration are administrative rules, managerial in- the practicing health care professional, and (iii) terests, and deficiencies of existing health policies reduce the distance between the data register and that stop short of fulfilling the needs of health- the user of information. care providers and the services itself4. One of the challenges facing this task is the The registration of data by the health care amalgamation of ergonomic studies with the providers within the purview of the SUS health physical and cognitive approach during develop- services, follows a centralized mode that is both ment of the technological solution, in order to in- disorganized and fragmented in logic4. The pro- corporate reality where the person is concerned; cedure begins with filling of forms by the user in other words, ‘understanding labor to improve at the time of entry into the primary care cen- it’9, i.e., to analyze work activity to facilitate the ter, and includes the collective actions of health creation of new and best methods, while preserv- promotion, community mobilization and also ing the physical, psychic, mental and social lives inter-sectoral information5. The system of data of health care workers10. collection is independent for each center, and The present paper has the following objec- becomes collective information only after reach- tives: To make a comparative study of the con- 893 Ciência & Saúde Coletiva, 21(3):891-902, 2016

crete experiences during data registration and time, were successful in producing results with usage of information, between one center where ‘Cartao SUS’ that were close to expectations12. informatics had been introduced, and another Among the 44 cities covereed by the pilot proj- one which followed the traditional system for ect, Aracaju had progressed considerably, broad- registration of data. To identify the expectations ened the tools and integrated the system of data of health care professionals about informatics, registration of primary care with the specialized before it becomes a reality. To study the experi- chain and the system of complementary medical ences of people who work in places where this examinations13. The local management formulat- technological innovation has been introduced. ed rules for the control, evaluation, auditing and To evaluate the factors that may influence the ad- demand regulation of functions, and laid down herence of the professional to the new system of guidelines along which the primary chain could working. classify risks and severity of patients’ conditions, During the implementation of the pilot allow proper selection of priorities, highlight the project of SCNS, some conflicts were observed most needed ones, and search for equityand so- regarding changes in the daily routine of profes- cial justice. sional practices, due to a disruption of set, ha- The city of João Pessoa, capital of Paraíba bitual practices acquired over years of working. state, Brazil, was chosen to represent a hypothet- This was probably related to resistance to the ical situation before computerization, or ‘With- procedure of data registration. Hypothetically, out SNCS’, as it is geographically close to Aracaju, the resistance shown by health care profession- and similar in regional, environmental and pop- als would more likely, be related to problems and ulation characteristics. delays created by the new procedure of working, A total of seven primary care units (five cov- rather than an overall antagonism towards com- ered by the Family Health Program (PSF) and puters. two ‘traditional’ outpatient clinics with special- The present research project is based on the ists on their panel), were selected based on the principle that the ergonomic study of the prac- following criteria: acceptance of the research by tical aspects of work before and after techno- unit managers, permission for the researchers logical innovation, is important to modify and to fill out questionnaires and conduct and voice minimize changes. The study questions whether record interviews during working hours. Data the electronic health register obstructs ongoing harvesting was carried out by the same research- work and if so, whether this could be the reason er who had earlier followed the procedures for for resistance, in which case, outline the remedial implementation of ‘Cartão SUS’ in Aracaju. The measures to be adopted. tools of data harvesting included the questionnaire, an itinerary of interviews and the diary of field work. Methodology Participation by health care professionals was entirely voluntary, and under informed consent. A transversal qualitative and comparative study Of the total number of persons interviewed, 96 was conducted to evaluate the perceptions of completed the questionnaire (40 ‘Without SCNS’ professional healthcare workers11, who collected and 56 ‘With SCNS”). 50 interviews were voice and recorded data about patients’ medical his- recorded (32 Without SCNS and 18 With SCNS), tory/ongoing treatment at primary care centers, and transcripts prepared, each of 20 to 40 min- during the year 2005. Units providing primary utes duration. health care, that were following/not following The nature of occupation and number (in the Health Card System (SCNS) were compared brackets) of the sample subjects in the two se- for work procedures These units will hereafter be lected cities of João Pessoa and Aracaju, were, referred to as ‘With SCNS’ and ‘Without SCNS’. respectively: community health agents (11 and The municipality of Aracaju, which is the 18); physicians (9 and 16); nursing and dentistry capital of Sergipe state in Brazil, was selected as assistants (8 and 6); nurses (3 and 6); dentists (3 representative of a working unit ‘With SCNS’, and 3); managers (1 and 2); other professionals for the following reasons. Implementation of the of superior level like social assistants, psychol- Health Card system had been launched in year ogists, educational psychologists, nutritionists, 2000, and the pilot project was regarded as a role speech therapists and pharmacists (5 and 5). model, because the city’s primary care centers The personal questionnaire comprised sub- retained the original concepts and at the same jective questions about perceptions of the pro- 894 Gava M et al. Gava fessionals with regard to the following topics: tion were 60.0% and 55.0% respectively, with the (i) views about the data register; (ii) personal remaining workers being educated only up to the experience with computers in general; (iii) per- high school level. ceptions about existing facilities, and the possi- The age group of participants was between bility of advancement with/without the aid of 21 and 50 years, slightly more elevated in João computers; (iv) difficulties or limitations when Pessoa. 58.0% had more than 15 years of profes- using computers to register information; (v) as- sional experience, while 25.0% had less than five pects of work conditions that need revamping in years experience. Figures for work experience in the new situation, before (anticipatory) and after Aracaju were 32.0% (more than 15 years) and computerization; (vi) familiarity with patterns 38.0% (less than five years). With regard to work followed by the SUS systems of information, and at SUS, a majority of the participants had been (vii) some specific aspects of the computerized hired since less than 5 years: 58.0% in Aracaju system. (‘without computers’), and 85.0% at João Pessoa Questionnaires filled by the professionals (‘with computers’). were interpreted theme wise, as follows: Theme 1 – based on the choice of alternatives; Theme Repercussions related to the time for data 2 - by the option of yes or no; Themes 3 to 7 registration over the work procedures - by the degree of importance, need or knowledge assigned (given by rating on a zero to five An obvious change brought about by imple- scale). The answers were classified and grouped mentation of the computerized system, was the into three categories: 0 to 1 – few; 2 to 3 – inter- substitution of handwritten registration forms mediate, and 4 to 5 – high. For data analysis, the with typed computer forms. Data on expecta- following types of software were used: Epi-Info tions about time revealed that, in João Pessoa 2003 version and Excel 2003. city, where the system had not yet been com- Covering the same topics as the question- puterized, 90.0% participants anticipated that naire, the interview method was aimed at getting the registration procedure would be shorter af- information about the practices being followed. ter computerization, but data from Aracaju, the computerized city, indicated that only 34.5% of the professionals agreed that this would happen Results (Graphic 1). At João Pessoa, perceptions about the possibility of complaints from users about Results are presented according to the topics cov- delays prior to treatment, were low. In contrast, ered in the questionnaire, complemented by in- this was a frequent complaint made to 83.0% formation provided in interviews. Graphs make of the professionals at Aracaju. As perceived by a comparative representation of data (‘Without 61.8% of the professionals (‘With computers’) SCNS’ and ‘With SCNS’) from questionnaires, against 52.6% of the professionals (‘Without expressed as percentages. Differences above 10% computers’), the need for simultaneously attend- between the two municipalities, and agreement ing to the patient, and typing out the data on the above 50% among the professionals who rated keyboard, increased the time taken to complete topics as ‘high’ (4 to 5) are highlighted. The results consultation. were divided into five groups, as given under. Data from interviews indicated that the time taken for both manual and electronic data entry Profile of the health professionals was short. The participating professionals (João who participated in the research Pessoa) felt that manual registration required time but was easy; professionals at Aracaju said In the city of João Pessoa, which followed the that more time was needed than before, because traditional (’Without computer’) system of data speed and efficiency with computers needed spe- registration, 55.0% of the participants worked cific training in addition to strategies of adapta- with the PSF (Program of Family Health), where- tion. as Aracaju (‘With computer’), recorded 68.0% I had too much difficulty because we are not participants – mainly women – working on the used to this new system..... When it comes to the project, with an overall participation of 82.0% in family’s health, you need to give detailed informa- the two cities. 60% participants totaled 40 hours tion (Physician – PSF – ‘Without computer’) of work per week; the percentage figures for spe- Data from the interviews indicated that there cialists and persons with higher level of educa- is a certain consensus regarding the positive role 895 Ciência & Saúde Coletiva, 21(3):891-902, 2016

Complaints of the patient for the delay of care 36,8- 83,0

Little time for simultaneously attending to the patient, and typing out the data on the keyboard 52,6- 61,8

Speeding up the process of patient care 90,0- 34,5

100,0 50,0 0,0 50,0 100,0

City without SCNS City with SCNS

Graphic 1. Percentage of professionals who agreed with the items related to limits of time at work.

“Agree” – this was considered for values 4 and 5, and affirmative answers to each item. Percentage was calculated over the total number of professionals who answered each item.

of informatics in (i) speeding up the process of search by the standardized first name listed in the patient care, and (ii) facilitating usage of the doc- International Classification of Diseases, which is umented information to solve health issues thyrotoxicosis [hyperthyroidism]. It would considerably diminish all this bu- On one occasion, I took about 40 minutes reaucracy..... Everything would be more accessible searching for the cod of nip [and not bite]..… Some- (Nurse – PSF – ‘Without computer’) times the machine goes out of order, and we have to In the manual system, the flow of specialized switch it off and re-start it…… The codes are very procedures was commenced with manual filling large” (Physician – PSF – ‘With computer’). of forms, and the clue for identification was the During the implementation of SCNS, there patient’s phone contact with a central number, was a continuous process of refinement. Initially which was considered a slow process. the network connecting the units with the reg- The consultation time that we lose as a re- ulation sector, needed to be dialed up, but with sult..… We keep on trying, trying, and trying the time, the units graduated to an online network phone number for half an hour, and we fail (Nurse system, and delays, if any, were related to the – PSF – ‘Without computer’) breakdown of the system. The increase in time consumption after com- Prior to computerizing, request for medical puterization was one of the main problems for examinations and complementary evaluations professionals’ non-adherence to this system for were controlled by health care workers, who is- capture of electronic data. sued (quota wise) printed paper forms for this This is the biggest complaint…, the complaint purpose. The data for scheduling appointments is related to the time taken…We deal with some re- was transmitted by phone or internet to the sistance, however, they register without precision… higher authorities. The integration of the pri- they say that too much time is lost with TAS, it is mary care centers to the regulation sector altered slow (Manager – PSF – ‘With computer’). the scheduling of appointments/procedures, and Registration of official codes and/or names came to be intermediated by TAS. is essential to cut down procedural time, and This is good for the patients, as they don´t need increase consultation time, but this aspect was to go out of the unit, they don´t need to repeat the generally neglected in manual registration. Ig- initial process at the reception every time they have norance of correct medical terminology neces- an appointment, every fifteen, twenty days, or sitated time-consuming search trials that needed once/twice a month…....it can be resolved without adapting to. For example, registration of a hy- the need of a doctor’s consultation (Administrative perthyroidism case required the professional to assistant – PSF – ‘With computer’). 896 Gava M et al. Gava When there are genuinely no vacancies in But we don´t have proper infrastructure..… hospitals, the doctor prioritizes cases according Ventilation, proper illumination, physical to risk factors, and relegates less serious cases to space…… proper training could improve many the bottom of the list, so that the patient is unaf- things (Nurse – PSF – ‘Without computer’). fected by the quota system, and leaves the consul- In the municipality of João Pessoa (‘Without tation room with an officially written request for computer’), the majority of units of PSF were the necessary diagnostic tests. rented houses adapted for the purpose. This house is not suitable for a health unit…. Work conditions and the relationship look at the pharmacy… There are some closets in with data registration the hallway (…) Sometimes when I admini8ster a vaccine, there is a mother here, another there, then The staff in the primary centers at João Pessoa a person passes by, and I have to stop in the middle (‘Without computers’) were unanimous regard- (Nursing assistant – PSF – ‘With computer’). ing the need to change the existing infrastruc- The common unit ‘without computer’ pres- ture to accommodate technology: illumination ents structural and/or construction problems: (100%), physical space (97.5%), air circulation The lack of structure, the physical space, too (100%), temperature regulation (97.5%), and many things need to change...... That room.….. furniture (chair - 100%; table - 92.5%). In the is bigger, more aired…,, they built a wall and it units at Aracaju (‘With computer’). the above- turned into two clinics, but with only one hammock mentioned features of infrastructure needed to for both of them! (Physician – non PSF – ‘Without improve for 49.1% to 68.1% of the staff; more- computer’). over, the staff also realized the need to alter the At Aracaju (‘With computer’), complaints furniture (table - 87.3%; chair - 83.6%). 49.1% were mainly related to ergonomic questions of of the staff employed in units covered by SCNS furniture and equipment: complained of osteomusculoarticular symptoms The machine was placed improperly..... the (repetitive stress injury), as against 13.5% in the machine occupies half of the wall space, but there non-computerized place (Graphic 2). is no suitable chair, the keyboard is not properly

Proper table to the computer 92,5 87,3

Suitable chair to computer 100,0 83,6

Care room area 100,0 69,1

Illumination 100,0 52,7

Air circulation 100,0 50,9

Problems of osteomusculoarticular symptoms (repetitive stress injury) 13,5 49,1

Temperature 97,5 48,1

100,0 50,0 0,0 50,0 100,0

% City without SCNS % City with SCNS

Graphic 2. Percentage of professionals who agreed with the items about the need for improving work conditions.

lowered….. The worst part is the size of this mon- Pessoa staff (‘without computer’) and 70.0% of itor…… I have to stand awkwardly [bent down], the Aracaju staff (‘With computer’). because the light falls on this spot and it is not pos- The computerization process of data col- sible to see” (Physician – PSF – ‘With computer’). lection was seen to safeguard medical records against the risks of loss and damage when com- Quality of registration pared to the traditional manual method of hand- for information usage written records. We have, for example, all the registers of vac- A lower proportion of staff from Aracaju cination... Even if medical records are lost, or mis- (‘Without computer’) were in agreement about placed due to negligence by the person writing the aspects of data recovery from patients, and re- data, we can recover it (Manager – PSF – ‘With duction of manual work procedures. A majority computer’). of staff disagreed that SCNS had facilitated (i) The benefits expected from computerization, scheduling of referrals, (ii) diagnosis, treatment were expected to bring improvements in work and decision making, and (iii) access to informa- procedures by easing and speeding up recovery tion (for patients) about themselves (Graph 3). of all registered data. 52.6% of the Aracaju (‘With computer’) staff We should have a feedback…… I asked for a found it easier to register the diagnoses coded prosthesis, I don´t know if they already made it.….. according to the International Code of Diseases They only return when it gets too tight (Dentist – (CID-10), whereas only 21.7% of the João Pessoa PSF – ‘Without computer’). (‘Without computer’) staff found it so. Percep- Realization about the importance of collec- tions about facilities accompanying standard- tive statistical data and recovery of individual ization of data was evident in 97.4% of the João data (through extracts of consultations), was evi-

It facilitates the recovery of data on the patient 100,0 64,8 It facilitattes diagnosis 21,7 52,6 coding by CID-10

There is a reduction of the 85,0 51,9 manuscript work Helps scheduling of referrals 87,5 43,6

Helps diagnosis, treatment and 75,0 28,3 decision making

Helps access to information (for 66,7 27,3 patients) about themselves

Contribute to standardization of 97,4 70,4 data and information There are doubt about the ethics 27,0 54,7 of access to information

100,0 50,0 0,0 50,0

% City without SCNS % City with SCNS

Graphic 3. Percentage of professionals who agreed with the items about professional practice and data quality for managing information.

“Agree” – this was considered for values 4 and 5, and affirmative answers to each item. Percentage was calculated over the total number of professionals who answered each item. 898 Gava M et al. Gava dent in the primary care units (’With computer’). Introduction of technology and the digital In the case of a hypertensive patient, you can inclusion of health workers see if he is being monitored….., take an extract of the consultation…. obtain statistical data….. It is Digital inclusion is the ability of individuals/ a good tool” (Nurse – PSF – ‘With computer’). groups to access and use technologies for infor- Ultimately, the usage of information was re- mation/communication. The introduction of lated both to the ‘modus operandi’ and responsi- technology in SUS is a step towards digital inclu- ble professional practice, which made visible the sion, and 92.5% of the staff working in non-com- good quality of service, and imparted more con- puterized systems expected this development to fidence to the uses of information in epidemiolo- take place; 60.0% of the staff accepted it as a re- gy and planning of action. ality; 31.5% of SCNS staff believed they had no The staff are already able to make a better eval- difficulty in using computers, and 59.5% foresaw uation about the diagnostic examinations that are some difficulties. Technical expertise in infor- really needed…. We increased the number of no- matics was expected to take longer for 62.2% of tifications by 70% (Manager – non PSF – ‘With the workers (‘Without computers’), and 28.9% computer’). staff (‘With computer’) felt that learning would SCNS was of great value to managers: it gave take a long time. Graphic 4 shows that 41.5% of visibility to the guiding principles of SUS, im- staff (‘With computers’) appreciated that this proving the access of population and equity in training helped in using technology outside the the services. workplace at SUS, and 74.4% (‘Without comput- Since the ‘Cartão SUS’ was implemented, the ers’) felt the same way. patients on reaching the unit, have access to their Although the staff at Aracaju (‘With comput- needs…..a way of care……If they enter the system, er’) considered it important to computerize the they go to a regulation site; depending on severity registration procedure, and go one step further of their case, they will be given priority over others by using still more advanced technology, TAS did (Manager – PSF – ‘With computer’) not present the complete range of a computer’s functionality.

Contributes to enter the 92,5 60,0 professional in the IT

Helps IT learning 74,4 41,5 outside of SUS

It would have a hard time working 59,5 31,6 with computer

It would take a long time to learn to work with computer 62,2 28,9

100,0 50,0 0,0 50,0 100,0

% City without SCNS % City with SCNS

Graphic 4. Percentage of professionals who agreed with the items about personal relationship with computers.

Technology is part of evolution, we have to broadening the scope of professional work, caus- move towards it…. Only when it is applied we start ing them to become ‘polyvalent’16. facing some difficulties […] (Nurse – PSF – ‘With computer). Repercussions of work procedures In brief, it may be said that, as the process on time for data registration of electronic registration approaches and incor- porates the aspects of software and hardware of One would expect that computerization universal usages, it will enhance the healthcare would speed up at least part of the work process, professionals’ perceptions of digital inclusion. but contrary to expectations, the present study did not find this as an immediate outcome. The reason behind this is that logic and cognitive Discussion abilities suitable for the new technology, are such that specialized training is required for work to Profile of staff participating in research attain a certain level of speed. The task of typing the data was added to the responsibility of pa- In the field of health care, the process of tient care, and therefore, the time taken for task computerizing does not necessarily lower the completion became more, e.g., there was an in- requirement for number of employees, unlike in crease in the number of complaints about delay other workplaces like banks14. However, the com- for seeing the doctor. puterization process makes managers and health Computerization increased the time need- care staff responsible and accountable for the way ed for the physician to finish each consultation. they use this technology. Therefore, it compels Consequently, professionals exhibited a lack them to learn and acquire abilities beyond health of adherence to the computerization process; care, such as understanding terms/tables/coding, these observations were also identified in an- which are incorporated in the software, grasping other research study17. In the present study, the new concepts, and applying these in specific areas main causes observed were the need to wait for of their daily routine at the workplace. diagnostic examination outcomes before taking After initiation of the s computerization pro- action; the need to document the case, and the cess, the need arose for adapting to the internet, frequent need for searching for information. and incorporating/improving procedures that From an epistemological point of view, tech- were previously neglected in the non-comput- nological evolution, particularly regarding health erized style of work. For example, the medical information, provides the advantages of read- data registers of SUS needed frequent updates to ability, accessibility, and the automatic and fast guarantee precision while identifying users in all recovery of data. According to Clancey18, barriers phases of the integral health assistance program. exist because there is rigidity of software in the The implementation of SCNS motivated lo- areas of interaction with patient care, as pro- cal mangers to invest in improvements such as: grams have not yet developed the capacity to re- organization and orientation of work towards produce perceptions, or the ability to improvise a digital style of management; construction of and interpret human actions. proper health units; improving job plans and ca- reers; carrying out public selections; hiring new Work conditions and the relationship employees;, developing the required abilities; with data registration anticipating new needs of the service, and implementation of the program named Modelo de The practical implementation of SCNS Saúde Todo Dia15. (mainly by TAS), means a substantial change in The recruitment of new employees encour- the ‘manner of organizing the work itself, and the aged the entry of young professionals skilled means of work (knowledge and tools) of the ac- in the use of modern technological resources, tivities in the health sector’19. with the additional qualities of scholarliness and The new physical requirements of the com- knowledge relevant to the needs of the service. puterization process are perceived by health pro- It may be stated that computerizing of health fessionals as factors that increase repetitiveness: sector services brought about modifications like awkward posture, the risks of spine problems, adding the task of typewriting to manual writing; and proneness to lesions of repetitive stress inju- creating new logic among users, which formed ry. The cognitive requirements of the new work- the basis for their demands on SUS services, and ing style include: need for memorization, focus- 900 Gava M et al. Gava ing of attention, comprehension, perception of and accomplished procedures, by the operational hidden pathways within the program, and the model and logic of applicatives; (iii) soft technol- functionalities of the system. Overall, the process ogy, or the care itself, formulated by the model of requires a differentiated approach – a combi- attention, and guided by SUS policies. nation of a cognitive intelligence with a unique To Merhy, the productional restructuring logic regarding non-computerized procedures20. of the health sector, where intellectual work is The software represents a case of intellectu- predominant, overcomes innovations represent- al technology: it molds the cognitive structures ed by the equipment, or the hard and soft-hard of the work organization, modifies care prac- technologies. It is essential to recognize that soft tices, and at the same time, calls for changes in technology has a special significance in the pro- environment and networks that are instituted21. cess of production in health26, such that it trans- The complex domain of health and health care forms and reorganizes by determining new inno- services, influences the integration of technolo- vations in professional care, thereby developing a gy into a sequence of interactions encompassing virtuous circle of innovations. shift of values in a central and typical characteris- In primary care, the integrative approach of tic scenario with complex cognitive tasks22. PSF is innovative, as the health practices reorga- The electronic registration system and pro- nize knowledge, identify new problems/needs in cess must answer ‘questions related to operation, health assistance, stimulate other cultural organi- functionality and epidemiology of the services, zations, and guide the trinomial execution plan becoming an instrument of management’23 for of information-decision-action27. improving the nation’s health system. Information is of strategic value to profes- The generation of information in this com- sional practice that is associated with the ‘results plicated world of health care, must gather con- of its application in planning, programming cepts and patterns in a way that avoids repetition and evaluating services, for improving both in- and redundancy of data registration, allowing the dividual care and public health’28. The quality of appearance of an integrated information system data aggregates values, and imparts objectivity to that attends to the needs of users, managers and knowledge about the health situation and the ep- staff. The interface of the software and the stan- idemiologic picture, which will serve as a strate- dardization of information in health, determine gic source for intervention in a given population. the scope of the system’s integration24. The use of information technology in the field of health, increases the responsibility of the Quality of data for generating information professionals, improves the notification of diseases under vigilance, and reduces the time needed The daily usage of information (which is very for investigation and intervention in reality. The important), will be determined by the quality of automatic accessibility of reports frees manag- technology within the machines being used, and ers to efficiently pursue their work in managing, this is what represents the reality of health work. controlling, evaluating, and regulating activities This facility was appreciated by professionals at and procedures, and reflecting about the social a point when all the hard work rendered it easy particularities of the area under management. to recover the medical history of patients, and helped in both prognosis and treatment of a case. Participation of technology in digital Progress is inevitable, because electronic registra- inclusion of the health care professional tion lowers risks, standardizes concepts that can be grouped together, and gives visibility to ac- The obligatory use of computers at the work- tions that make it easy to diagnose and monitor place contributes to digital inclusion in life out- the line of health care, allowing for planning and side the workplace as well. As the professional decision making. starts working with the machine, there is a great- Merhy25 states that technologies are made up er probability of carrying out other trials of ac- of an imaginary comprehension under three types cess to computers, and overcoming myths and of bags, which for SCNS can be represented thus: prejudices regarding technology. In general, the (i) hard technology, or the service terminal of SUS more adequate the technology employed in a – TAS, the connection between net and system ar- specific area of work for the purpose of catering chitecture; (ii) hard/soft technology, the amount to its specific needs, the greater the inclusion. of knowledge of professional practice that is Digital inclusion at workplaces, like digital in- housed in the programs, standardized by solicited clusion in schools29, is an opportunity to broad- 901 Ciência & Saúde Coletiva, 21(3):891-902, 2016

en the motivation for using technology at home, health care professionals. Technology does not during free time, and in community services; that incorporate the real activity of work, and when is, it can open up avenues for the advancement of anticipated benefits (like reduction of delay when social inclusion of workers30. attending to patients) are not attained, then the task of typewriting becomes just one more task. The increase in time taken to carry out the task is Conclusion a sign of disapproval of technology, and can par- tially explain non-adherence to the newly intro- The transformation of work procedures in pri- duced procedures. mary care centers by electronic registration of In actual practice, it is not feasible to com- data, as studied in the implementation of the puterize all the health care structures, as the soft National Health Card System (Cartão SUS), on technology present in human interaction is rep- a comparative basis between two locations with resented by improvising and interpretation of and without computerization, made explicit the human relations, and hence not reproducible by realities encountered during health work. The means of software and computerized systems. study also elucidated details of organization, and On the other side, the incorporation of infor- modifications of needs and physical conditions mation systems technology in health care, directs at work. From a futuristic point of view, the en- the production of data closer to the professional tire exercise serves to pave the way for innova- who registers the data. Hence, it tends to reflect, tions that get re-arranged in a virtuous cycle of with more precision, the reality felt at the edge. professional practices. In other words, with computerization, there is a Computerization in health does not reduce questioning approach to the rationality of data employment; rather, it increases the need for in- registration and its relevance to information us- corporating other tasks by health professionals, age. organizes and de-centralizes tasks like data har- The accumulated experiences of computeri- vesting, and aggregates knowledge, standards and zation procedures can very well support improve- tables of procedures of SUS, which were hitherto ments in health care practices, in addition to in- distant from professional practice. creasing the efficiency and quality, measurable by The delay in data insertion into the comput- broadening the accessibility, equality, integrality erized system, is one of the chief complaints of and humanization of health care services.

Collaborations

M Gava responsible for the design, conduct of research, analysis and interpretation of results and writing of the article. ELA Mota, as the guiding thesis, participated in the conception and design, the analysis and review of the results and the article. D Palhares and LS Ferreira edited the text, reviewed data and complement the literature review.

Acknowledgements

We thank the Indian company Content Concepts for English review. 902 Gava M et al. Gava References

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