ABSTRACT

OBJECTIVE:

To measure the degree of integration of the Electronic Citizen’s Record (PEC - Prontuário Eletrônico do Cidadão) of the e-SUS Primary Care Strategy (e-SUS AB - Estratégia e-SUS Atenção Básica) in the view of other Brazilian´s National Health Information Systems (SNIS - Sistemas Nacionais de Informação em Saúde), relating to the internal political-organizational structure of the Brazilian Ministry of Health (MH).

METHODS:

This is a qualitative case study. Data collection was carried out through document analysis and semi-structured interviews. In the first stage, we sought to clarify how many SNIS were in use in the Primary Care (PC) of the Unified Health System between 2013 and 2017. Then, we defined as criterion the maintenance of data collection interfaces by the Ministry of Health even after the implementation of the PEC/e-SUS Primary Care in order to measure the integration.

RESULTS:

31 SNIS were identified in Primary Care. We observed that 12 of them were completely integrated and 15 presented no unification of interfaces related to PEC/e-SUS Primary Care. Another 4 have partial integration. By correlating these data with the political-organizational structure of the MS, we observed a greater integration with the systems managed by the Department of Primary Care and a persisted fragmentation in SNIS, especially those under the management of the Health Surveillance Department (Secretaria de Vigilância em Saúde). The disparity between the integration of the PEC/e-SUS Primary Care with the Health Surveillance SNIS is a sign of the persistence of the division and the false dichotomy between Health Care and Health Surveillance practices and processes in the Ministry of Health – even 30 years after the foundation of the SUS and unification of the state structures of social security hospital care and federal public health in MH.

CONCLUSION:

Although still insufficient, the systems integration carried out by the e-SUS Primary Care Strategy, which focuses on reducing user interfaces, can be considered a new fact on the SUS information and information policy agenda.

DESCRIPTORS:
Electronic Health Records; Control of Forms and Records; eHealth Policies; System Integration Primary Health Care

INTRODUCTION

In Brazil, health professionals, managers, and researchers live with dozens of health information systems in their work environments, with little or no integration between them. This problem has been reported since the 1980s¹1 Pinto LF, Freitas MPSA, Figueiredo AWS. Sistemas Nacionais de Informação e levantamentos populacionais: algumas contribuições do MS e do IBGE para a análise das capitais brasileiras nos últimos 30 anos. Cienc Saude Coletiva. 2018;23(6):1859-70. https://doi.org/10.1590/1413-81232018236.05072018
https://doi.org/10.1590/1413-81232018236... and is related to the fragmentation of the State’s bureaucratic structures²2 Moraes IHS, Gómez MNG. Informação e informática em saúde: caleidoscópio contemporâneo da saúde. Cienc Saude Coletiva. 2007;12(3):553-65. https://doi.org/10.1590/S1413-81232007000300002
https://doi.org/10.1590/S1413-8123200700... , the absence of semantic and technological standardization³3 Jardim SVB. The Electronic Health Record and its contribution to healthcare information systems interoperability. Procedia Technol. 2013;9:940-8. https://doi.org/10.1016/j.protcy.2013.12.105
https://doi.org/10.1016/j.protcy.2013.12... –⁴4 Laguardia J, Domingues CMA, Carvalho C, Lauerman CR, Macário E, Glatt R. Information system for notifiable diseases (Sinan): challenges in developing a national health information system. Epidemiol Serv Saude. 2004;13(3):135-46. https://doi.org/10.5123/S1679-49742004000300002
https://doi.org/10.5123/S1679-4974200400... , and the low maturity of Information and Communication Technology (ICT) governance policies in organizational services⁵5 Gottschalk P. Maturity levels for interoperability in digital government. Gov Inf Q. 2009;26(1):75-81. https://doi.org/10.1016/j.giq.2008.03.003
https://doi.org/10.1016/j.giq.2008.03.00... .

Between 2013 and 2018, 54 National Health Information Systems (SNIS - Sistemas Nacionais de Informação em Saúde) were identified in operation in Brazil, maintained by the Ministry of Health (MH), including systems for registration, notification of diseases and conditions, control and logistics of supplies and medicines, electronic medical records, laboratory management, accounting control of the production of procedures, among others⁶6 Coelho Neto GC. Integração entre Sistemas de informação em Saúde: o caso do e-SUS Atenção Básica [dissertação]. São Paulo: Escola Paulista de Medicina, Universidade Federal de São Paulo; 2019.. Furthermore, they are incorporated into these other systems developed or acquired by states and municipalities.

Often, poor integration requires that the same data be filled in different interfaces, generating rework and increased costs, so turns out to be necessary to maintain several technological solutions with redundant functions. This duplication of records has an impact on the quality of the databases, making analysis and cross-referencing difficult and impacting the reliability of the information produced⁴4 Laguardia J, Domingues CMA, Carvalho C, Lauerman CR, Macário E, Glatt R. Information system for notifiable diseases (Sinan): challenges in developing a national health information system. Epidemiol Serv Saude. 2004;13(3):135-46. https://doi.org/10.5123/S1679-49742004000300002
https://doi.org/10.5123/S1679-4974200400... ,⁷7 Araújo YB, Rezende LCM, Queiroga MMD, Santos SR. Sistemas de Informação em Saúde: inconsistências de informações no contexto da Atenção Primária. J Health Inform. 2016;8(5):164-70..

Since the creation of the Brazilian Unified Health System (SUS), the state has adopted strategies to improve communication and integration between the SNIS. By the initiative of the Pan American Health Organization, the Inter-Management Network for Health Information (Ripsa - Rede Intergerencial de Informações para a Saúde) was created in the late 1990s, intending to produce relevant and integrated information for decision-making in health⁸8 Risi Júnior JB. Informação em saúde no Brasil: a contribuição da Ripsa. Cienc Saude Coletiva. 2006;11(4):1049-53. https://doi.org/10.1590/S1413-81232006000400025
https://doi.org/10.1590/S1413-8123200600... . In the 2000s, the implementation of the SUS National User Registry (Cadsus - Cadastro Nacional de Usuário do SUS) was intended to unify the basic registration information of every Brazilian citizen who uses the SUS. The first information management model of Cadsus provided for the registration, storage, and protection of data as attributions of the municipalities, in a decentralized model that faced serious problems related to duplicate registrations, besides the existence of multiple numbers of the National Health Card (CNS - Cartão Nacional de Saúde) for the same user is frequent. This happens when the same user goes to a health service without his card, requiring the reception to make a new registration for him. This problem was only resolved with a structural change in data governance by the centralization of databases in MH. Still, only 14 SNIS were connected to the Cadsus national base in 2014⁹9 Ministério da Saúde (BR), Departamento de Informática do SUS. Interoperabilidade Sistema-SUS: apresentação. Brasília, DF; 2014 [cited 2018 Dec 4]. Available from: https://portalarquivos2.saude.gov.br/images/pdf/2015/maio/15/2b-Apresentacao-WebServices-CONASSEMS.pdf
https://portalarquivos2.saude.gov.br/ima... .

In 2013, the MH launched the e-SUS Primary Care Strategy (e-SUS AB - Estratégia e-SUS Atenção Básica), One of its objectives has been to promote greater integration between the SNIS operating in the Primary Care Units¹⁰10 Rezende FAVS, Soares MF, AC. Os sistemas de informação em saúde no Sistema Único de Saúde. In: Leandro BBS, Rezende FAVS, Pinto JMC, organizadores. Informações e registros em saúde e seus usos no SUS. Rio de Janeiro: Editora Fiocruz; 2020. p.70-117. by the unification of interfaces data collection in the Simplified Data Collection (CDS - Coleta de Dados Simplificada) and in the Electronic Citizens Record (PEC - Prontuário Eletrônico do Cidadão) software, developed in partnership with the Universidade Federal de Santa Catarina (UFSC) and made available free of charge to the Municipal Health Departments.

According to the MH, in 2016, data sent to the national e-SUS Primary Care database was carried out by 97% of Brazilian municipalities¹¹11 Ministério da Saúde (BR); Conselho Nacional dos Secretários Municipais de Saúde. Acompanhamento e-SUS AB: nota informativa. Brasília, DF; 2016 [cited 2017 May 12]. Available from: https://www.conasems.org.br/wp-content/uploads/2016/02/images_E_SUS.pdf
https://www.conasems.org.br/wp-content/u... and the electronic medical record would already be installed in 9,227 Primary Care Units, corresponding to 21% of the 42.6 thousand existing in 2017¹²12 Lora V. Funcionalidades do Prontuário Eletrônico do Cidadão. Rio Claro, SP-SP; 2018 [cited 2018 Dec 4]. Apresentação realizada no 32° Congresso de Secretários Municipais de Saúde do Estado de São Paulo. Available from: http://www.cosemssp.org.br/congresso/wp-content/uploads/2018/05/vanessa-lora-funcionalidades-da-estrat%c3%89gia-e-sus-ab.pptx
http://www.cosemssp.org.br/congresso/wp-... . These numbers may vary by region and criteria used. For example, Lima (2018) carried out a diagnostic study on the implementation of the e-SUS Primary Care Strategy in Minas Gerais, concluding that in only 49.1% of the municipalities the strategy had actually been implemented¹³13 Lima PKM. Implementação da Estratégia e-SUS Atenção Básica em municípios mineiros [dissertação]. São João Del-Rei, MG: Universidade Federal de São João Del-Rei; 2018.. Moreover, the advanced degree of implementation of the public policy in question seems unequivocal.

When can we say that two or more systems are integrated? In the field of Public Health, this understanding was generally related to the crossing of different bases, increasing data reliability, and producing new health information¹⁴14 Morais RM, Costa AL. Uma avaliação do Sistema de Informações sobre Mortalidade. Saude Debate. 2017;41 Nº Espec:101-17. https://doi.org/10.1590/0103-11042017S09
https://doi.org/10.1590/0103-11042017S09... ,¹⁵15 Oliveira C, Oliveira LCS, Guimarães MJB, Lyra T. Integração dos bancos do SIM e do SINAN: a contribuição da vigilância dos óbitos relacionados às doenças de notificação compulsória no município de Recife. In: Anais da 5ᵃ EXPOEPI - Mostra Nacional de Experiências Bem-sucedidas em Epidemiologia, Prevenção e Controle de Doenças; 2-6 dez 2005; Brasília, DF. Brasília, DF: Ministério da Saúde; c2006. p. 95.. In turn, the debate on systems integration in the field of health informatics has been around technological solutions aimed at greater automation of communication between systems (mediated by standardized messages and files, syntactic interoperability) or semantic compatibility between the terms used in each of them (semantic interoperability)¹⁶16 Moreno RA. Interoperabilidade de Sistemas de Informação em Saúde [editorial]. J. Health Inform. 2016 [cited 2018 Dec 4];8(3):I. Available from: http://www.jhi-sbis.saude.ws/ojs-jhi/index.php/jhi-sbis/article/viewFile/502/268
http://www.jhi-sbis.saude.ws/ojs-jhi/ind... . However, there is another aspect of systems integration that has been little addressed in academic production and in public health information and informatics policies. We refer to the so-called integration of user interfaces¹⁷17 Nebe K, Zimmermann D. Aspects of Integrating User Centered Design into Software Engineering Processes. In: Jacko JA, editor. Human-computer interaction. Interaction Design and Usability; Part I, HCI 2007. Berlin (DE): Springer-Verlag; 2007. p. 194-203. (Lecture Notes in Computer Science; nº 4550). https://doi.org/10.1007/978-3-540-73105-4_22
https://doi.org/10.1007/978-3-540-73105-... , related to the design and usability of systems by workers and managers in the services responsible for inserting the primary data in the systems.

Focusing on the user-centered, we propose to describe and measure the integration of the PEC with other SUS Primary Care SNIS, relating it to the political-organizational structure of the MS and testing the hypothesis of the systems fragmentation relationship with the bureaucratic structure of the state.

METHODS

This case study assumes as object the relationship among the e-SUS Primary Care Strategy and the SNIS in Primary Care use, as proposed by Yin (2015)¹⁸18 Yin RK. Estudo de caso: planejamento e métodos. 2. ed. Porto Alegre: Bookman; 2013.. In the first stage, we sought to clarify how many SNIS were in production in Primary Care between the years 2013 to 2018 – necessary due to the existing conflict between official data sources. The following MH documents related to health information and informatics were analyzed: Information Technology Master Plans (PDTI - Planos Diretores de Tecnologia da Informação) from 2014 to 2015¹⁹19 Ministério da Saúde (BR). Plano Diretor de Tecnologia da Informação – PDTI 2014-2015. Brasília, DF; 2013., 2016²⁰20 Ministério da Saúde (BR). Plano Diretor de Tecnologia da Informação – PDTI 2016. Brasília, DF; 2016. and 2017 2018²¹21 Ministério da Saúde (BR). Plano Diretor de Tecnologia da Informação - PDTI 2017-2018. Brasília, DF; 2017.; National Policy on Health Information and Informatics (PNIIS - Política Nacional de Informação e Informática em Saúde) published in 2016²²22 Ministério da Saúde (BR), Secretaria Executiva, Departamento de Monitoramento e Avaliação do SUS. Política Nacional de Informação e Informática em Saúde. Brasília, DF; 2016.; Datasus Management Report (Relatório de Gestão do Datasus) from 2011 a 2014²³23 Ministério da Saúde (BR), Departamento de Informática do SUS. Datasus: Relatório Executivo da Gestão 2011-2014. Brasília, DF; 2015.23; Terms of Reference of the processes related to the electronic auction of contract No. 22/2014 (Termos de Referência dos processos referentes ao pregão eletrônico do contrato) regarding the contracting of a software factory to provide information technology services for the development and maintenance of information systems²⁴24 Ministério da Saúde (BR). Termo de Referência da Licitação nº 0019/2013 (Processo administrativo nº 25000.090683/2012-51). Objeto: Pregão eletrônico - contratação de empresa especializada para prestação de serviços técnicos de desenvolvimento e manutenção de sistemas de formação; e contagem de pontos de função. Brasília, DF; 2017.; finally, Notice No.01 / 2017 in relation to the computerization program of the Primary Care Units²⁵25 Ministério da Saúde (BR), Secretaria Executiva, Subsecretaria de Assuntos Administrativos, Coordenação Geral de Material e Patrimônio. Edital de credenciamento nº01/2017 (Processo Administrativo n° 25000.072832/2017-13). Objeto: Contratação de empresas para implantação de prontuário eletrônico nas Unidades Básicas de Saúde (UBS), por meio da contratação de solução que contemple serviços de hardware, software, manutenção de equipamentos de TI, treinamento dos profissionais de saúde e suporte técnico para o uso do Prontuário Eletrônico, conforme especificações do presente Projeto Básico e de seus apêndices, para atendimento ao Ministério da Saúde. Brasília, DF; 2017..

The responses of the MS motivated by two requests for access to information based on Law 12,527/2011 (Access to Information Law) were also analyzed, where it was asked about the list of systems in production in MH (nº 25820004082201795) and in Primary Care (nº 25820005771201806). The complete content of the responses can be accessed openly on the page of the Electronic Information System to Citizen (e-SIC - Sistema Eletrônico de Informações ao Cidadão)^aaControladoria-Geral da União (BR). Sistema Eletrônico do Serviço de Informação (e-SIC) e Fala.BR – Módulo de Acesso à Informação: acesso à informação e ouvidoria em uma única plataforma. Brasília, DF; 2021 [cited 2021 oct 20]. Available from: http://esic.cgu.gov.br .

In the second stage, the objective was to understand the situation of the integration of each of the SNIS in operation in Primary Care with the Electronic Citizen’s Record (PEC) of the e-SUS Primary Care, clarifying whether the integration actions allowed workers and local managers to discontinue the use of the respective SNIS. Three key informants were interviewed: two members of the development and management team of the e-SUS Primary Care Strategy in the period from 2013 to 2017 and one member of the technical team of a national entity representing the municipal health secretariats. The analysis also included contributions from the experience of one of the researchers in the daily use of PEC/e-SUS Primary Care and other SNIS from his work as a physician in a basic health unit in Rio de Janeiro. Only those where there was consensus among the above sources were considered as integrated SNIS.

Finally, we analyzed the degree of integration of the SNIS with the internal organization chart of the MH. In the period from 2013 to 2018, the formal structure of the top management of the agency remained stable, with the existence of seven Secretariats²⁶26 Ministério da Saúde (BR), Secretaria Executiva, Departamento de Monitoramento e Avaliação do SUS. Planejamento Estratégico do MS 2011–2015: resultados e perspectivas. Brasília, DF; 2013 [cited 2018 Dec 4]. Available from: https://bvsms.saude.gov.br/bvs/publicacoes/planejamento_estrategico_ministerio_saude_resultados.pdf
https://bvsms.saude.gov.br/bvs/publicaco... : Health Care (SAS), Executive (SE), Health Surveillance (SVS), Strategic and Participatory Management (SGEP - Gestão Estratégica e Participativa), Indigenous Health Special (SESAI - Especial de Saúde Indígena), Work Management and Health Education (SGTES - Gestão do Trabalho e Educação na Saúde) and Science Technology and Strategic Inputs (SCTIE - Ciência Tecnologia e Insumos Estratégicos). The Primary Care Department (DAB - Departamento de Atenção Básica), the main sector responsible for formulating and managing the e-SUS Primary Care Strategy, was linked to SAS.

The research was presented and approved by the Ethics Committee of the São Paulo da Universidade Federal de São Paulo Hospital (Unifesp), opinion nº 2.179.195. Respondents signed an Informed Consent Form (FICF) and the interviews were conducted and recorded using the Skype ® software.

RESULTS

A total of 31 SNIS were found in operation in Primary Care between 2013 and 2018, most of them under the technical management of the SAS or SVS (Box).

It was found that the e-SUS Primary Care Strategy performed complete unification of user interfaces with 12 of the 31 nationally-based SNIS in use in Primary Care and incomplete integrations with four SNIS. Another 15 SNIS had no degree of integration, as shown in Table 1.

Integration varied according to the internal sector of the MS responsible for the technical management of the system (Table 2). Although the SAS and SVS have similar numbers of SNIS in use in Primary Care, there was an important disparity between the integration of their respective systems with the e-SUS Primary Care.

DISCUSSION

The SIS fragmentation is a phenomenon reported by several authors when analyzing health information policies in different regions of the world²⁷27 Mudaly T, Moodley D, Pillay A, Seebregts C. Architectural frameworks for developing national health information systems in low and middle income countries. In: Proceedings of the 1st International Conference on Enterprise Systems, ES, 2013; 2013 Nov 7-8; Cape Town, South Africa. p.1-9. https://doi.org/10.1109/ES.2013.6690083
https://doi.org/10.1109/ES.2013.6690083... –³¹31 Mahundi M, Kaasbøll J, Twaakyondo H. Health Information Systems Integration in Tanzania: tapping the contextual advantages. In: Proceedings of the IST Africa Conference; 11-13 May 2011; Gaborone, Botswana. p.1-11., but we did not find studies that dimensioned such fragmentation, based on the counting and description of the SNIS in operation. The record of 31 SNIS in use in Primary Care from 2013 to 2018 shows that the trend of fragmentation persists in the country, documented in Brazil in several technical studies³²32 Moraes IHS. Informação em saúde: da prática fragmentada ao exercício da cidadania. Rio de Janeiro: Hucitec;1994.–³⁴34 Fonseca FCS. Sistemas de informação da atenção à saúde: da fragmentação à interoperabilidade. In: Ministério da Saúde (BR), Secretaria de Atenção à Saúde, Departamento de Atenção Básica. Sistemas de Informação da Atenção à Saúde: contextos históricos, avanços e perspectivas no SUS. Brasília, DF; 2015. p.9-21..

In countries that promoted projects to change this scenario, the focus has been on better integration between national databases³⁵35 Sæbø JI, Kossi EK, Titlestad OH, Tohouri RR, Braa J. Comparing strategies to integrate health information systems following a data warehouse approach in four countries. Inform Technol Dev. 2011;17(1):42-60. https://doi.org/10.1080/02681102.2010.511702
https://doi.org/10.1080/02681102.2010.51... –³⁷37 Kanter AS, Borland R, Barasa M, Iliams-Hauser C, Velez O, Kaonga NN, et al. The importance of using open source technologies and common standards for interoperability within eHealth: perspectives from the Millennium Villages Project. Adv Health Care Manag. 2012;12:189-204. https://doi.org/10.1108/S1474-8231(2012)0000012013
https://doi.org/10.1108/S1474-8231(2012)... or the establishment of semantic and technological standards for recording and exchanging information between different systems³⁸38 Higman S, Dwivedi V, Nsaghurwe A, Busiga M, Rulargirwa HS, Smith D, et al. Designing interoperable health information systems using Enterprise Architecture approach in resource-limited countries: a literature review. Int J Health Plann Manag. 2019;34(1):e85-99. https://doi.org/10.1002/hpm.2634
https://doi.org/10.1002/hpm.2634... ,³⁹39 Liyanage H, Krause P, Lusignan S. Using ontologies to improve semantic interoperability in health data. BMJ Health Care Inform. 2015;22(2):309-15. https://doi.org/10.14236/jhi.v22i2.159
https://doi.org/10.14236/jhi.v22i2.159... . No describing studies were about SNIS integration, focusing on the user interfaces.

When we analyze the result of the integration carried out by e-SUS Primary Care and the political-organizational structure of the MH, we noted that there was greater integration with the SNIS under the direct management of the DAB (Figure) and a low integration with systems from other secretariats beyond of SAS itself.

In the case of integration among SVS SNIS, including the Epidemiological Surveillance, Care for the Population with HIV/AIDS and Hepatitis, birth, and mortality monitoring and immunization policies, we observed only a partial advance in the integration of the e-SUS Primary Care with the SI-PNI.

The most worrisome case seemed to be the SNIS of the Department of HIV/AIDS, not even mentioned in the list of SNIS in operation in Primary Care in the MH bidding for Primary Care Units computerization²⁵25 Ministério da Saúde (BR), Secretaria Executiva, Subsecretaria de Assuntos Administrativos, Coordenação Geral de Material e Patrimônio. Edital de credenciamento nº01/2017 (Processo Administrativo n° 25000.072832/2017-13). Objeto: Contratação de empresas para implantação de prontuário eletrônico nas Unidades Básicas de Saúde (UBS), por meio da contratação de solução que contemple serviços de hardware, software, manutenção de equipamentos de TI, treinamento dos profissionais de saúde e suporte técnico para o uso do Prontuário Eletrônico, conforme especificações do presente Projeto Básico e de seus apêndices, para atendimento ao Ministério da Saúde. Brasília, DF; 2017..

The disparity between the integration of e-SUS Primary Care with the SVS and SAS SNIS can be considered a sign that some degree of historical division and false dichotomy between Health Care and Health Surveillance practices and processes still persists⁴⁰40 Campos CEA. O desafio da integralidade segundo as perspectivas da vigilância da saúde e da saúde da família. Cienc Saude Coletiva. 2003;8(2):569-84. https://doi.org/10.1590/S1413-81232003000200018
https://doi.org/10.1590/S1413-8123200300... , even after 30 years since the foundation of the SUS and unification of the state structures of social security hospital care and federal public health in MH.

The governability of the managing area of e-SUS Primary Care over other SNIS proved to be a variable to be considered in the integration process, as there was a higher success rate of integration of e-SUS Primary Care with DAB’s own SNIS when compared to the SNIS under the management of other MH departments and secretariats.

The frequency and intensity of the use of SNIS in health services was a lesser factor, given that SNIS with intense use at the local level of the SUS had incomplete or not started integration, such as the Sisreg, Horus, and Sinan Net.

CONCLUSION

Considering the complexity of integration between legacy systems in organizations, it is reasonable that after five years of the e-SUS Primary Care Strategy implementation, the operation of SNIS in Primary Care is just partially integrated. Although still insufficient, the integration of systems carried out with about ⅓ of the SNIS in operation in Primary Care, focused on reducing user interfaces, is a new fact on the agenda of the SUS information and information policy.

The relative uniqueness of the Brazilian experience of integration between health information systems is remarkable. Brazil promoted the creation of a state electronic medical record as a kind of “hub” for other SNIS created by the government, more specifically by the federal sphere. Although we believe that the “developmentalist” stance taken by the Brazilian state contributes to the expansion of computerization of primary care in the country, we pay attention to the need for greater integration of the large volume of market software in use by states and municipalities in the national SNIS bases, following the trend of investment in public regulation policies associated with greater semantic and technological interoperability between systems, as observed in other countries.

REFERENCES

Publication Dates

History