ABSTRACT

The objective was to analyze the use of e-SUS Primary Health Care reports in the work routine of Family Health teams (eSF) in the Federal District (DF). This is a descriptive study of data from the on-site Assessment and Quality Action Plan of the 1st evaluation cycle of the Primary Health Care Qualification Program, between 2021 and 2022. All 607 teams were included. Associations between Health Regions were identified using Chi-square tests, p-value < 0.05. To quantify problems and actions, Data Mining techniques were used. The majority of eSFs in the DF denied using any e-SUS APS report in their work routine (53.23%). The reports that the eSF used most were production reports (54.43%), and management reports the least (31.60%). The regions with the highest proportion of use were Central-South (73.67%), and with the lowest, Southwest (34.56%), p < 0.0001. Some of the main problems described were intrinsic to e-SUS APS (errors, failures, system instability and lack of unification) and others were related to extrinsic issues (lack of knowledge, inconsistency and lack of registration). The teams listed in their Action Plans, as a priority, the training for correct use of the information system.

KEYWORDS
Information systems; Electronic health records; eHealth policies; Health planning; Public health systems research.

Introduction

The increase in the world population, together with the growing expectation of effective treatments and better quality of life, are placing increasing pressure on health systems. Thus, health continues to be one of the most important social and economic challenges worldwide, requiring new and more advanced scientific and technological solutions^{11 Dehnavieh R, Haghdoost A, Khosravi A, et al. The District Health Information System (DHIS2): a literature review and meta-synthesis of its strengths and operational challenges based on the experiences of 11 countries. Health inf manag. 2019;48(2):62-75. DOI: https://doi.org/10.1177/1833358318777713
https://doi.org/10.1177/1833358318777713... ,22 Aceto G, Persico V, Pescapé A. Industry 4.0 and health: Internet of things, big data, and cloud computing for healthcare 4.0. J Ind Inf Integr. 2020;18:100129. DOI: https://doi.org/10.1016/j.jii.2020.100129
https://doi.org/10.1016/j.jii.2020.10012...} . In response to such needs, since the early 1990s, significant investments have been made in Information and Communication Technologies (ICT), aiming to positively impact access, efficiency and quality of virtually any health-related process^{33 Wager KA, Lee FW, Glaser JP. Health care information systems: a practical approach for health care management. Columbia: John Wiley & Sons; 2021.}.

The analysis of the health situation by Primary Health Care (PHC) is guaranteed to be important in the health planning and programming cycle, as it allows the identification, description, prioritization and explanation of the population’s health problems, with the aim of identifying social needs and determining action priorities^{44 Teixeira CF. Planejamento em saúde: conceitos, métodos e experiências. Salvador: EDUFBA; 2010.}. In this sense, Health Information Systems become important resources for carrying out this situational analysis, in order to support the identification of the health condition and the epidemiological situation of the territory for the decision-making by management, as well as establishing priorities in the planning of the actions of health teams.

In 2013, the then Department of Primary Care (DAB) of the Ministry of Health implemented the e-SUS APS Strategy, with the intention of restructuring PHC information at the national level, making electronic medical records available for use by health teams. The e-SUS APS Strategy refers to a computerized and qualified process for achieving an electronic Unified Health System (SUS), which operates the Health Information System for Primary Care (SISAB), established through Ordinance GM/MS No. 1,412, of July 10, 2013. Currently, there are two software systems for data collection: Simplified Data Collection (CDS) and Electronic Citizen Record (PEC)<sup>55 Ministério da Saúde (BR), Secretaria de Atenção à Saúde. Estratégia e-SUS Atenção Básica e Sistema de Informação em Saúde da Atenção Básica - SISAB. Brasília, DF: Ministério da Saúde; 2013.

6 Ministério da Saúde (BR), Secretaria de Atenção à Saúde. E-SUS Atenção Básica: Manual do sistema com coleta de dados simplificada: CDS. Brasília, DF: Ministério da Saúde; 2014.

7 Ministério da Saúde (BR), Secretaria de Atenção à Saúde. e-SUS Atenção Básica: Manual de uso do Sistema com Prontuário Eletrônico do Cidadão PEC - Versão 3.1. Brasília, DF: Ministério da Saúde; 2018.-88 SISAB: Sistema de Informação em Saúde para a Atenção Básica. Versão 2.1.240605. Brasília, DF: DATASUS; [data desconhecida].</sup>.

While the CDS is only capable of capturing consolidated data on care, the PEC enables the construction of a database with sociodemographic and clinical information on each patient, which is stored in the system during the patient’s care, enabling longitudinal monitoring. In addition to being entered into the national database, SISAB, these care data feed back into the local e-SUS, allowing the generation of various types of reports about the enrolled population. The various types of reports can be used by different actors and are grouped in the PEC into four categories: managerial, consolidated, operational and production^{77 Ministério da Saúde (BR), Secretaria de Atenção à Saúde. e-SUS Atenção Básica: Manual de uso do Sistema com Prontuário Eletrônico do Cidadão PEC - Versão 3.1. Brasília, DF: Ministério da Saúde; 2018.}.

It is essential that healthcare teams plan their actions in relation to local needs, which translates into situational analysis. Reports, which are prepared based on data from care and registration of the enrolled population, are important tools to guide this planning. Improvements in the quality of care provision are the result of this strategic alignment, which involves the efficient use of resources and the optimization of processes^{44 Teixeira CF. Planejamento em saúde: conceitos, métodos e experiências. Salvador: EDUFBA; 2010.}.

Furthermore, e-SUS APS aims to promote a reduction in dependence on paper and to reduce the workload involved in collecting, inserting, managing and using information in PHC, allowing this data collection to be part of the activities already carried out by professionals, and not a separate activity. Consequently, it must also have information available in an easy and accessible way for PHC professionals, allowing the culture of using information to be expanded, in the most integrated way possible, for planning actions and improving the quality of health care for the population^{99 Araújo JR, Araújo DC, Machado LD, et al. Sistema e-SUS AB: percepções dos enfermeiros da Estratégia Saúde da Família. Saúde debate. 2019;43(122):780-92. DOI: https://doi.org/10.1590/0103-1104201912210
https://doi.org/10.1590/0103-11042019122...} .

However, this system is understood as one of the complex readjustments of work processes, as it becomes yet another instrument used daily by health professionals. In addition, there are technical aspects that make the incorporation of this technology difficult, such as internet access and failures of the system itself^{1010 Matsuda LM, Évora YD, Higarashi IH, et al. Informática em enfermagem: desvelando o uso do computador por enfermeiros. Texto Contexto Enferm. 2015;24(1):178-86. DOI: http://dx.doi.org/10.1590/0104-07072015002760013
http://dx.doi.org/10.1590/0104-070720150... ,1111 Damásio AS, Weimer SC, Rosa MC. Evolução do Sistema de Informação em Saúde para Atenção Básica. Estácio Saúde. 2018;7(1):81-8.}.

By virtue of the Cooperation Agreement between the Ministry of Health and the National Council of Health Secretaries (CONASS), the Federal District (DF) has the role of pilot municipality for the routine execution of certification processes (tests) of the new features and improvements of the new versions of e-SUS, so that they can be updated in the production environment of the PHC health services in the other locations in the country. Thus, the DF has a privileged and challenging space for health managers and workers, as it has the first access in the country to the respective new features and resources of the versions launched by the developer laboratory.

The objectives of the article were to analyze the use of e-SUS APS reports in the work routine of Family Health teams (eSF) in the DF, within the scope of the Primary Health Care Qualification Program (Qualis-APS) according to the DF and the Health Regions (RS) (Central, Central-South, East, North, West, Southwest and South), in addition to evaluating the problems and actions related to the theme described in the Quality Action Plan (PAQ) of the eSF.

Material and methods

Study design and scenario

This is a descriptive study with a mixed approach of data from the first evaluation cycle of the Qualis-APS Program, collected between September 2021 and November 2022. Implemented in 2019 and regulated by Ordinance No. 131, of April 14, 2023^{1212 Secretária de Estado de Saúde (DF). Portaria nº 131, de 14 de abril de 2023. Dispõe sobre o Programa de Qualificação da Atenção Primária à Saúde. Diário Oficial do Distrito Federal. 2023 abr 17; Seção 1:5.}, Qualis-APS aims to qualify the management and services provided by the PHC of the DF, articulating actions of evaluation, training and certification of health teams.

Health management in the Federal District is decentralized into seven RS Superintendencies that are grouped according to the 35 Administrative Regions (RA). The RS with their respective RA are: Central (Asa Sul, Asa Norte, Cruzeiro, Sudoeste/Octogonal, Lago Norte, Lago Sul, Varjão e Vila Planalto); South-Central (Candangolândia, Cidade Estrutural, Guará, Park Way, Núcleo Bandeirante, Riacho Fundo I, Riacho Fundo II, Setor de Indústria e Abastecimento e Setor Complementar de Indústria e Abastecimento); East (Paranoá, Itapoã, São Sebastião, Jardins Mangueiral e Jardim Botânico); North (Planaltina, Arapoanga, Sobradinho, Sobradinho II e Fercal); Southwest (Águas Claras, Arniqueira, Água Quente, Recanto das Emas, Samambaia, Taguatinga e Vicente Pires); West (Ceilândia, Brazlândia e Sol Nascente/Pôr do Sol); South (Gama and Santa Maria)^{1313 Secretaria de Saúde (DF) [Internet]. Distrito Federal: SSDF; 2023. Regiões de Saúde; 2024 jun 3 [acesso em 2023 maio18]. Disponível em: https://www.saude.df.gov.br/regioes-de-saude
https://www.saude.df.gov.br/regioes-de-s...} .

Regarding the structure and organization of the actions and services of the PHC of the DF, in the sphere of regional health management, thus, taking into account the improvements, reorganization and planning in the infrastructure, in the work process and in the results, there is the composition of seven Regional Directorates of Primary Health Care (DIRAPS), with the support and articulation of 100 Primary Care Service Managements (GSAP), distributed throughout the territories covered by the PHC, in which the local managers of the health units are located.

To this end, according to the August 2023 figures from the internal control of the Primary Health Care Coordination (COAPS), in the actions and services of primary care in the DF, there is the following structure: 175 Basic Health Units (UBS), with 622 eSF; 355 Oral Health teams (eSB); 12 Prison Primary Care teams (eAPP); 11 Complementary Psychosocial Teams for Prison Primary Care; 5 Street Clinic (eCR) teams; and 52 Multiprofessional teams in Primary Health Care (eMulti).

According to the report on linked records, from July 2023, in the Ministry of Health’s SISAB, the DF currently has a total of 2,130,921 citizens monitored in the PHC health actions and services. Furthermore, with regard to the population coverage estimated by the eSF, in line with the last record for the period of April 2023, in the Strategic Planning System (SESPlan) of the SES-DF network, the percentage of coverage of the indicator is 66.29%.

Participants

All DF eSFs established prior to the start of the first evaluation cycle were included, totaling 607 health teams. Teams established immediately after this time interval were not included in the evaluation process, due to the impossibility of participating since the Self-Assessment - in the first phase of the Qualis-APS evaluation cycle.

Data collection system

The Qualis-APS assessment process is organized into cycles composed of four phases: I - Self-Assessment (AA); II - Preparation and execution of the Quality Action Plan (PAQ); III - On-site assessment; IV - Certification^{1212 Secretária de Estado de Saúde (DF). Portaria nº 131, de 14 de abril de 2023. Dispõe sobre o Programa de Qualificação da Atenção Primária à Saúde. Diário Oficial do Distrito Federal. 2023 abr 17; Seção 1:5.}.

In the first stage, teams respond to the Self-Assessment within the Qualis-APS Platform, which is a reflective and formative process for teams that aims to verify compliance with the set of quality standards established. Subsequently, among the standards evaluated with the lowest indexes, the teams select those they consider to be most relevant and draw up an action plan stipulating deadlines for compliance in the PAQ phase. This phase should be understood as an opportune moment to continue the reflections already initiated in the AA. Then, interviewers external to SES/DF carry out an in-person visit to each UBS for the on-site Assessment, on dates previously scheduled to apply quantitative questionnaires on aspects related to the quality of the APS. Finally, the teams are certified according to a ranking of best scores.

For this study, initially, a selection of the questions contained in the On-Site Assessment related to the use of the e-SUS report by the eSF was used. Subsequently, the bank of problems and actions related to e-SUS listed in the PAQ was used.

On-site assessment

Interviews were conducted between July and October 2022 using the ‘eSF Module’ instrument. This module provides analysis of team performance and identification of strengths and weaknesses in the healthcare work process. Although the Qualis-APS assessment is participatory and co-produced, data collection for the third assessment phase - On-site Assessment - is carried out by evaluators external to the DF State Health Department (SES-DF), under the coordination of the research team, on previously defined dates. The interviewers were systematically selected and trained, and a pre-test was applied in the month prior to the start of data collection. The questions raised, mainly related to clarity and appropriateness of language, were modified. Data were collected using REDCap software installed on tablets. The eSF module was answered by a representative of each team.

Among the subtopics that structure the eSF module, for the present study, only the item that corresponded to the use of reports in the eSF work routine, called ‘Planning and monitoring of actions and services offered by the team’, was used. They were questioned about the use of the four types of reports generated in e-SUS^{77 Ministério da Saúde (BR), Secretaria de Atenção à Saúde. e-SUS Atenção Básica: Manual de uso do Sistema com Prontuário Eletrônico do Cidadão PEC - Versão 3.1. Brasília, DF: Ministério da Saúde; 2018.}:

• Consolidated reports: these are reports that allow a view of the consolidated registration status, according to the selected date, allowing the user to see the most up-to-date information.

• Production reports: these are reports that allow an aggregated view of information, such as: individual, dental and home care (SAD), collective activity, procedures, among others, as well as production summary reports.

• Operational reports: these are reports that present individualized and identified information on the health situation of citizens in the territory. These reports are only accessed by UBS workers, as they contain data related to the individual care of the citizen.

• Management reports: presents specific and essential information about the functioning of the Health Unit, such as absenteeism and number of appointments, observing data generated during the process flows present in the daily life of the service.

For each type of report (production, consolidated, operational and management), the following uses were questioned about: planning the provision of services; monitoring individuals and families; territorial division with other teams; mapping comorbidities/health situation in the population; mapping social, cultural, environmental and vulnerability aspects; evaluation of indicators agreed upon in the Local Management Agreement (AGL), which is a form of contracting, within the scope of performance management, adopted by SES-DF. The AGL is part of the SES-DF regional health management program, institutionalized by Decree No. 37,515, of July 26, 2016. The main results of the AGL, which measure the performance of actions within the scope of PHC, are disclosed every four months. In total, ten indicators and their respective targets are monitored.

Quality Action Plan (QAP)

After analyzing the frequency of use of e-SUS reports in the teams’ work routine according to the responses from the eSF Module of the On-Site Assessment, we sought to identify the problems faced by the teams for the effective use of e-SUS through the PAQ.

Before the on-site assessment, the teams self-assessed and selected quality standards that were not being fully met to develop an action plan. To develop the PAQ, the planning tool used is an adaptation of the 5W2H matrix published on the Qualis-APS Program website. The teams develop an Action Plan with at least four of the 45 self-assessed quality standards. The quality standards for the health teams are organized into dimensions (actions in the territory, user care, work organization and planning) and their respective sub-dimensions.

The Microsoft Excel® spreadsheet with the PAQ responses from all healthcare teams was extracted from the Qualis-APS platform. Using the search tool, the number of teams that listed problems and actions related to the e-SUS APS reports was identified and, subsequently, the content was analyzed.

Data analysis

The data from the on-site assessment were extracted from REDCap, tabulated in Microsoft Excel® (version 16) and analyzed using the R language software. The results from the eSF Module of the on-site assessment were summarized in absolute and relative frequency (%) of each categorical question according to the Federal District and the seven RS (Central, Central-South, East, North, West, Southwest and South). Appropriate statistical techniques were applied to assess the relationship between the use of production, consolidated, operational and management reports and the RS of the Federal District.

To identify the presence of an association between the RS and the use of production, consolidated, operational and management reports, Chi-square tests of Variable Independence were performed. A significance level (α) of 5% was considered, i.e., establishing a 5% probability of rejecting the null hypothesis (H0) if it is true; the hypothesis of independence between the variables was rejected if the p-value was less than 0.05.

Content Analysis with data mining techniques was used to analyze the problems and actions arising from the Action Plans prepared by the teams. Data mining was performed through a quantitative evaluation of textual elements. Standard extraction and analysis techniques were used in the textual data through a statistical approach of the most frequent terms, and categories representing classification patterns, i.e. textual aggregates, were created. The cases that were transcribed, as an example of the application of the textual aggregates found, were identified by the acronym ‘eSF’ followed by the number of participation in the study.

Associations between words or terms were also assessed, i.e. syntagmatic and paradigmatic relations respectively. So-called ‘stop words’ were eliminated, i.e. words that are not relevant to the content (e.g. and, the). Filters were used to detect and count words frequently used in all texts. The weighting between the main words was presented in the form of a word cloud.

Ethical aspects

All participants signed an informed consent form. This study was approved by the Research Ethics Committee of the Faculty of Health Sciences of the University of Brasília (CAAE no. 29640120.6.0000.0030; opinion No. 5,396,127).

Results

In general, among the 603 participating eSFs in the Federal District, 53.23% denied using the reports in their work routine. Figure 1 illustrates the spatial distribution of the use of reports by RA. The average distribution of the use of reports by RA was classified by strata: 0.1 to 9.6 (Vicente Pires, São Sebastião, Samambaia, Fercal, Recanto das Emas, Água Quente/Recanto das Emas, Plano Piloto, Sobradinho II, Taguatinga and Arniqueira); 9.7 to 12.3 (Cruzeiro, Planaltina, Arapoanga, Paranoá, Lago Norte, Santa Maria and Sobradinho); 12.4 to 15 (Ceilândia, Jardim Botânico, Itapoã, Brazlândia and Águas Claras); 15.1 to 17.7 (Gama, Varjão, Riacho Fundo II, Sol Nascente and Pôr do Sol); 17.8 to 20.4 (Park Way, SCIA/Estrutural, Guará, Riacho Fundo I, Candangolândia and Núcleo Bandeirante). The blank regions have no record because they do not have UBS in their territory and are served in neighboring RA.

When making the association between the use of reports by RS, it is noted that all the results of the statistical tests presented a p-value lower than the significance level of 5%. This occurred due to the large discrepancy between the percentages for some regions, as presented in the tables and highlighted in the subsequent paragraphs.

Table 1 presents the data by RS. The Center-South region showed the highest proportion of use of reports (73.67%), while the Southwest (34.56%) and Central (38.88%) regions had the lowest proportion. Among the four types of existing reports, the ones most used by the eSF were Production (54.43%); followed by Consolidated (57.19%); and with the lowest proportion, Operational (45.42%) and Management (31.60%) reports (table 1).

The distributions of the use of each type of report by RS had statistically significant differences (p < 0.0001). The Central-South region also presented the highest proportion of use of each type of report in the work routine of the eSF, followed by the South region, while the Central region contained a lower proportion of use of Production reports (42.28%), and the Southwest region, a lower proportion in the use of Consolidated (44.73%), Operational (29.49%) and Management (22.09%) reports (table 1).

Table 2 shows the results of the use of reports according to each action for planning and organizing the service, stratified by RS of the DF. The action in which the eSFs made the most use of the Production and Consolidated reports was the evaluation of the indicators agreed upon in the AGL (63.35% and 63.18% respectively). The Central-South region had the highest proportion of use of the Production and Consolidated reports for all the actions listed, reaching values close to 100% when it came to use for evaluating indicators that are part of the AGL.

The Central region used the Production reports the least for planning and offering services (46.34%) and monitoring individuals and families (42.90%), in addition to being the one that used the Consolidated reports the least for monitoring individuals and families. The East region used the Production reports to a lesser extent than the others for mapping social, cultural, environmental and vulnerability aspects (30.88%), and territorial division with other teams (23.53%), this last action mentioned also had a low proportion of use of the Consolidated reports (25%). The Southwest region used the Production and Consolidated reports to a lesser extent for mapping comorbidities/health situation in its population (45.91% and 45.28% respectively) and evaluating the indicators agreed upon in the AGL (48.12% in both) (table 2).

In the Federal District, Operational and Management reports were less used in the territorial division of the eSF with other teams (35.99% and 26.53% respectively). Operational reports were used more for monitoring individuals and families (55.72%), and Management reports were used more for evaluating the indicators agreed upon in the AGL (41.79%). The Central-South region also led the ranking of use of Operational and Management reports, compared to the other regions (p < 0.0001) (table 2).

Table 3 shows the description of the number of mentions of e-SUS APS reports in the PAQs of health teams by region. There was a greater number of actions than problems, with a ratio of 2.7 actions/problems listed by the teams, but they were not necessarily interrelated.

In figure 2, we can see the representation of word clouds with the 100 words and a bar graph with the 20 bigrams mentioned the most in the list of problems and actions, related to the e-SUS APS reports. We can see that, after the term e-SUS APS, the most mentioned words in the list of problems are, in order: record; registration; report; lack; indicator; system; territory; monitoring; difficulty; update; inconsistency; errors; team; patient; data; population; failures; mistakes; pregnant woman; hypertensive. When analyzing the bigrams, we can see that some problems are directly related to some problem intrinsic to the e-SUS APS (errors, failures, system instability and lack of unification). Below are some examples:

Others are related to extrinsic issues (ignorance, inconsistency and lack of records). Below are some examples:

In the list of actions, after the term e-SUS APS, the most mentioned words were, in order: team; registration; report; patient; health; training; indicator; service; record; home visit, pregnant woman, user, consultation; Community Health Agent (ACS); request; consultation; training; data; area; active search. Regarding the bigrams of the actions, the large number of mentions of qualification and team training stands out, while others mentioned training specifically for ACSs (figure 2). It is worth noting that the teams needed to list actions that were under their governance.

Discussion

The issuance and use of information from information system reports for planning actions within the scope of primary care and service organization was a weakness found in most of the DF’s RS. The reports generated in e-SUS allow workers to view, in a summarized and systematized manner, the health actions carried out in the territory. However, less than half of the DF’s eSFs reported the use of e-SUS APS reports in the different actions of health planning and programming.

Among the types of existing reports, production reports were used the most by the Federal District’s eSFs. Some studies on the computerization of PHC have also prioritized production reports. In general, these studies admit that the teams’ productions can be forwarded to Sisab, through e-SUS or third-party systems, as a criterion for considering a UBS computerized<sup>1414 Avila GS. Difusão do Prontuário Eletrônico do Cidadão da Estratégia e-SUS AB em equipes de Saúde da Família [dissertação na Internet]. Belo Horizonte: Universidade Federal de Minas Gerais; 2020 [acesso em 2023 set 14]. 109 p. Disponível em: https://repositorio.ufmg.br/handle/1843/38620
https://repositorio.ufmg.br/handle/1843/...

15 Cielo AC, Raiol T, Silva EN, et al. Implementation of the e-SUS Primary Care Strategy: an analysis based on official data. Rev Saúde Pública. 2022;56(5):1-13. DOI: https://doi.org/10.11606/s1518-8787.2022056003405
https://doi.org/10.11606/s1518-8787.2022... -1616 Zacharias FCM, Schönholzer TE, Oliveira VC, et al. e-SUS Atenção Primária: atributos determinantes para adoção e uso de uma inovação tecnológica. Cad Saúde Pública. 2021;37(6):e00219520. DOI: https://doi.org/10.1590/0102-311X00219520
https://doi.org/10.1590/0102-311X0021952...</sup> .

Regarding the purpose, most regions use the reports to evaluate the indicators agreed upon in the AGL, while they showed an underuse of the reports, mainly for territorial division with other teams; mapping social, cultural, environmental and vulnerability aspects; and planning and offering services.

In this sense, it is worth noting that the AGL is an agreement that aims to strengthen the management model based on production results. There is an incentive for the more expressive use of reports in the analysis of AGL indicators, since, in 2020, this Agreement used four district agreement indicators and seven concerning the ‘performance’ component of the Previne Brasil Program^{1313 Secretaria de Saúde (DF) [Internet]. Distrito Federal: SSDF; 2023. Regiões de Saúde; 2024 jun 3 [acesso em 2023 maio18]. Disponível em: https://www.saude.df.gov.br/regioes-de-saude
https://www.saude.df.gov.br/regioes-de-s...} . Since 2019, Previne Brasil has established the financing model for PHC costs within the scope of the SUS^{1717 Ministério da Saúde (BR). Portaria nº 2.979, de 12 de novembro de 2019. Institui o Programa Previne Brasil, que estabelece novo modelo de financiamento de custeio da Atenção Primária à Saúde no âmbito do SUS, alterando a Portaria de Consolidação nº 6/GM/MS, de 28 de setembro de 2017. Diário Oficial da União. 2019 nov13; Seção 1:97.}. Nevertheless, the applicability of the reports issued in e-SUS APS can transcend the idea of a major focus on monitoring for financial transfer. The reports issued have great potential to ultimately become a tool for the management, monitoring, and evaluation of primary care actions and services, in addition to guiding health planning for the decision-making process^{1616 Zacharias FCM, Schönholzer TE, Oliveira VC, et al. e-SUS Atenção Primária: atributos determinantes para adoção e uso de uma inovação tecnológica. Cad Saúde Pública. 2021;37(6):e00219520. DOI: https://doi.org/10.1590/0102-311X00219520
https://doi.org/10.1590/0102-311X0021952... ,1818 Santos LP, Pereira AG, Graever L, et al. e-SUS AB na cidade do Rio de Janeiro: projeto e implantação do sistema de informação em saúde. Cad Saúde Coletiva. 2021;29(esp):199-204. DOI: https://doi.org/10.1590/1414-462X202199010232
https://doi.org/10.1590/1414-462X2021990... ,1919 Oliveira Junior JG. Subutilização, limites e potencialidades do Sistema de Informação em Saúde para a Atenção Básica (SISAB). Asklepion: Informação em Saúde. 2023;2(2):52-70. DOI: https://doi.org/10.21728/asklepion.2023v2n2.p52-70
https://doi.org/10.21728/asklepion.2023v...} .

Among the factors related to the non-use of e-SUS reports, some studies corroborate the problems listed in the teams’ action plans. A scenario of difficulties ranging from the lack of internet access to the lack of computers for data entry, in addition to the loss of information due to the lack of integration between the outsourced system and the e-SUS APS system, has been observed<sup>1414 Avila GS. Difusão do Prontuário Eletrônico do Cidadão da Estratégia e-SUS AB em equipes de Saúde da Família [dissertação na Internet]. Belo Horizonte: Universidade Federal de Minas Gerais; 2020 [acesso em 2023 set 14]. 109 p. Disponível em: https://repositorio.ufmg.br/handle/1843/38620
https://repositorio.ufmg.br/handle/1843/...

15 Cielo AC, Raiol T, Silva EN, et al. Implementation of the e-SUS Primary Care Strategy: an analysis based on official data. Rev Saúde Pública. 2022;56(5):1-13. DOI: https://doi.org/10.11606/s1518-8787.2022056003405
https://doi.org/10.11606/s1518-8787.2022... -1616 Zacharias FCM, Schönholzer TE, Oliveira VC, et al. e-SUS Atenção Primária: atributos determinantes para adoção e uso de uma inovação tecnológica. Cad Saúde Pública. 2021;37(6):e00219520. DOI: https://doi.org/10.1590/0102-311X00219520
https://doi.org/10.1590/0102-311X0021952...</sup> . The quality of the information has also been reported as one of the determinants that encourage or hinder the acceptance of the use of the system among its users, in addition to the possible underreporting in the system<sup>2020 Medeiros JB, Holmes ES, Albuquerque SG, et al. O e-SUS Atenção Básica e a coleta de dados simplificada: relatos da implementação em uma estratégia saúde da família. Rev APS. 2017;20(1):145-9. DOI: https://doi.org/10.34019/1809-8363.2017.v20.15784
https://doi.org/10.34019/1809-8363.2017....

21 Sacramento J. Números, casos e (sub) notificações: a vigilância epidemiológica e o boletim epidemiológico como tecnologias do biopoder. Cad Campo. 2020;29(supl):182-93. DOI: https://doi.org/10.11606/issn.2316-9133.v29isuplp182-193
https://doi.org/10.11606/issn.2316-9133....

22 Thum MA, Baldisserotto J, Celeste RK. Utilização do e-SUS AB e fatores associados ao registro de procedimentos e consultas da atenção básica nos municípios brasileiros. Cad Saúde Pública. 2019;35(2):e00029418. DOI: https://doi.org/10.1590/0102-311X00029418
https://doi.org/10.1590/0102-311X0002941... -2323 Gava M, Ferreira LS, Palhares D, et al. Incorporação da tecnologia da informação na Atenção Básica do SUS no Nordeste do Brasil: expectativas e experiências. Ciênc saúde coletiva. 2016;21(3):891-902. DOI: https://doi.org/10.1590/1413-81232015213.01062015
https://doi.org/10.1590/1413-81232015213...</sup> , problems also mentioned in the teams’ PAQ.

In the analysis of the PAQ, many professionals mentioned as a problem the fact that they did not know how to generate the indicators, nor was it part of their routine and work processes to have access to the data to perform analysis/planning of actions based on them. Regarding this aspect, a study that described the evolution of the SIS for primary care, from 2007 to 2017, showed that, even with training on the systems and their significant importance, the professionals of the eSF were not in tune with the use of the data collected and their use at the local level. It was also possible to identify the weakness and lack of knowledge in diagnosing diseases in the assigned areas, as well as planning health promotion and prevention actions based on the reports issued^{1111 Damásio AS, Weimer SC, Rosa MC. Evolução do Sistema de Informação em Saúde para Atenção Básica. Estácio Saúde. 2018;7(1):81-8.}.

Following the line of actions listed by the teams, there is recognition of the need for investment in training users of the systems that make up the e-SUS APS strategy, with a priority focus on ACS. According to other Brazilian studies, there is still great difficulty in both adequately collecting data and using the information to build health indicators. This fact can be attributed to a series of factors, among which one of the main factors is the lack of adequate training of professionals<sup>99 Araújo JR, Araújo DC, Machado LD, et al. Sistema e-SUS AB: percepções dos enfermeiros da Estratégia Saúde da Família. Saúde debate. 2019;43(122):780-92. DOI: https://doi.org/10.1590/0103-1104201912210
https://doi.org/10.1590/0103-11042019122... ,2222 Thum MA, Baldisserotto J, Celeste RK. Utilização do e-SUS AB e fatores associados ao registro de procedimentos e consultas da atenção básica nos municípios brasileiros. Cad Saúde Pública. 2019;35(2):e00029418. DOI: https://doi.org/10.1590/0102-311X00029418
https://doi.org/10.1590/0102-311X0002941... ,2424 Alves JP, Diniz IVA, França KTG, et al. Avanços e Desafios na Implantação do e-SUS Atenção Básica. 2º Congresso Brasileiro de Ciências da Saúde; 2017 Jun14-16; Campina Grande: Centro de Convenções Raymundo Asfora; 2017.

25 Rasia IC, Rosa AC, Rediss AN. A utilização dos sistemas de informação em uma instituição de saúde de Pelotas-RS. Rev Saúde Com. 2012;8(2):32-42.

26 Ribeiro MA, Muniz TBF, Albuquerque IMN, et al. Processo de implantação do e-SUS Atenção Básica em Sobral - CE. Rev Eletron Comun Inf Inov Saúde. 2018;12(3):258-67. DOI: https://doi.org/10.29397/reciis.v12i3.1364
https://doi.org/10.29397/reciis.v12i3.13... -2727 Lopes SPA, Araujo JS, Figueiredo LGM, et al. A evolução dos cadastros individuais no SISAB a partir do novo financiamento da Atenção Básica: um estudo descritivo. Revista de Atenção à Saúde - RAS. 2022;20(71):263-73. DOI: https://doi.org/10.13037/2359-4330.8388
https://doi.org/10.13037/2359-4330.8388...</sup> .

Furthermore, the results suggest that development efforts should focus on improving the system and reports, especially on promoting integration and interoperability with other health information systems; and restructuring the ways in which information is collected, processed, validated and used. Thus, it is expected that, with the evolution of the system, a greater number of teams will consider using the information from their territory generated in the e-SUS reports for planning and programming their actions<sup>1414 Avila GS. Difusão do Prontuário Eletrônico do Cidadão da Estratégia e-SUS AB em equipes de Saúde da Família [dissertação na Internet]. Belo Horizonte: Universidade Federal de Minas Gerais; 2020 [acesso em 2023 set 14]. 109 p. Disponível em: https://repositorio.ufmg.br/handle/1843/38620
https://repositorio.ufmg.br/handle/1843/...

15 Cielo AC, Raiol T, Silva EN, et al. Implementation of the e-SUS Primary Care Strategy: an analysis based on official data. Rev Saúde Pública. 2022;56(5):1-13. DOI: https://doi.org/10.11606/s1518-8787.2022056003405
https://doi.org/10.11606/s1518-8787.2022... -1616 Zacharias FCM, Schönholzer TE, Oliveira VC, et al. e-SUS Atenção Primária: atributos determinantes para adoção e uso de uma inovação tecnológica. Cad Saúde Pública. 2021;37(6):e00219520. DOI: https://doi.org/10.1590/0102-311X00219520
https://doi.org/10.1590/0102-311X0021952... ,2020 Medeiros JB, Holmes ES, Albuquerque SG, et al. O e-SUS Atenção Básica e a coleta de dados simplificada: relatos da implementação em uma estratégia saúde da família. Rev APS. 2017;20(1):145-9. DOI: https://doi.org/10.34019/1809-8363.2017.v20.15784
https://doi.org/10.34019/1809-8363.2017....

21 Sacramento J. Números, casos e (sub) notificações: a vigilância epidemiológica e o boletim epidemiológico como tecnologias do biopoder. Cad Campo. 2020;29(supl):182-93. DOI: https://doi.org/10.11606/issn.2316-9133.v29isuplp182-193
https://doi.org/10.11606/issn.2316-9133....

22 Thum MA, Baldisserotto J, Celeste RK. Utilização do e-SUS AB e fatores associados ao registro de procedimentos e consultas da atenção básica nos municípios brasileiros. Cad Saúde Pública. 2019;35(2):e00029418. DOI: https://doi.org/10.1590/0102-311X00029418
https://doi.org/10.1590/0102-311X0002941... -2323 Gava M, Ferreira LS, Palhares D, et al. Incorporação da tecnologia da informação na Atenção Básica do SUS no Nordeste do Brasil: expectativas e experiências. Ciênc saúde coletiva. 2016;21(3):891-902. DOI: https://doi.org/10.1590/1413-81232015213.01062015
https://doi.org/10.1590/1413-81232015213...</sup> .

It is worth noting that this study has limitations inherent to its cross-sectional and descriptive nature. However, given the recognized scarcity of studies on the subject in the Federal District, as well as the sample of all teams, the use of evaluation techniques in dimensions of self-assessment, preparation of an action plan and external evaluation allowed us to draw a baseline of the situation of use of the reports and the problems related to their non-use by the health teams of the PHC of the Federal District.

Conclusions

It was possible to identify that there are still aspects that hinder the incorporation of the use of e-SUS APS reports into the routine of the eSF. It is considered important that managers pay attention to the problems identified by team professionals, in order to determine the needs and advances to be made to ensure the effectiveness of the e-SUS APS system.

Also, professionals are often concerned about the reliability of the data collected and the information being produced. It is understood that improving the system and training professionals can be important strategies to ensure the quality of information and the planning of actions to support health interventions and decision-making.

Furthermore, it is worth noting that in the Central Administration (AdmC) of SES-DF, the organic units related to the PEC e-SUS APS theme, and by virtue of the Cooperation Agreement of the Ministry of Health and Conass, the DF has the role of pilot municipality for the routine execution of certification processes (tests) of the novelties and improvements of the new versions, so that they can be updated in the production environment of the PHChealth services. Thus, the DF has a privileged and challenging space for health managers and workers, having the first access in the country to the respective novelties and resources of the versions launched by the developer laboratory.

References

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