Implementation of the e-SUS Primary Care system: Impact on the routine of Primary Health Care professionals*

Objective: to understand how the implementation of the e-SUS Primary Care system has been processed and its impact on the daily life of the health teams. Method: a qualitative research study, conducted in a municipality in the inland of the state of São Paulo with professionals who work in Primary Health Care and use the e-SUS Primary Care system as a work tool. Semi-structured interviews and thematic data analysis were used with Kotter’s three-phase approach. Results: a total of 17 professionals, nurses, physicians, dentists and community agents were interviewed. The implementation of e-SUS Primary Care and its impact on the daily life of health teams were understood in terms of mandatory implementation; weaknesses for implementation, such as absence of material resources and implicit imposition for the use of the system; fragile training for deployment and learning from experience. Conclusion: a harmful incentive process was observed, conducted from the perspective of institutional pressure, use of the system to justify the work performed and, on the other hand, there was the creation of collaborative learning mechanisms between the teams.


Introduction
In the health sector, information supports the planning, decision-making process and implementation of public policies; however, limitations related to the permanence of manual data records, difficulties in accessing computer equipment, and poor training of human resources can negatively impact on its operationalization (1) .
Lack of skill can be seen as a barrier in the daily lives of the professionals, when it comes to maintaining the quality of the data, either due to lack of skill or to time constraint (2) . These negative impacts can be minimized through the perception of the professionals about the quality factors of the information system and by the motivation to use it (3) . Since it is essential to pay attention to the interaction between the demands of the professional, the technology and the desired context (4) .
In health, changes are recognized as important; however, they are interspersed with challenges due to the administrative complexity of this sector and, for the implementation of any change be successful, it is necessary for health organizations to be able to manage such a process. There are aspects that can be cited as forbidding for implementing computerized information systems in Brazil, such as impasses during the implementation, difficulties in the preparation of the professionals, as well as the deficiency of the organizational structure (5) .
In this implementation process, elements such as vision, skills, encouragement, resources and action plan lead to a real change; however, the absence of one of these elements in the process can cause feelings such as anxiety, confusion and frustration (6) .
In Brazil, information is used as an instrument for the management of the Unified Health System (Sistema Único de Saúde, SUS), related to health surveillance, production monitoring and financial transfer, and may highlight administrative management and often distance itself from the needs of the health services (7) . In the implementation of information systems, structure and technical support are needed to support the process and, even when made available, obstacles can still occur at the local level. The criterion of the Ministry of Health to determine whether the BHUs use the system is sending data to the SISAB; however, there is no information or analysis about the real implementation scenario or about how the process was inserted and perceived by the professionals. Thus, this study aimed to understand the implementation process of the e-SUS AB system and its impact on the daily life of the health teams.

Method
This is a qualitative research study, conducted in 2018 in a municipality with a population of approximately 25,000 inhabitants and a high Human Development Index (HDI) (between 0.7 and 0.8) (10) , in the inland of the state of São Paulo. The health network of the municipality is composed of seven teams of family health strategies, an emergency care service, a home care service, a specialized dental care center, a specialty outpatient clinic and a Psychosocial Care Center (Centro de Atenção Psicossocial, CAPS). The study scenario consisted of six family health strategies that had the e-SUS AB with PEC implemented, located in three peripheral and three central areas of the city.
The study population consisted of 17 health team professionals (nurses, community health agents, dentists, physicians and nursing technicians) with experience in using the e-SUS AB system for at least six months and who were open to dialogue, selected for convenience. The criterion was the repetition and saturation of the data to determine the number of interviews, and at least two professionals per category (11) . To process the data from the interviews, thematic analysis was used, contemplating the following stages: familiarization with the data; generation of initial codes; research, review, definition and name of the themes and production of the report (12) . After transcribed, with the help of the Google Docs text editor by means of the "voice typing" tool, the interviews were coded according to professional category and ordinal number and, from this, the reading of the transcribed material began with the insertion of comments recorded by the researcher, as the entries caught her attention.
Next, the initial codes were elaborated and, subsequently, the phase of grouping and/or separation of codes took place (12) . The initial codes were inserted in the Word text editor, on a blank page, to verify the possibility of groupings among them, always seeking to ensure correlation between the information. Later, the potential themes were transferred to a sheet of paper and, with the use of colored pens and adhesive papers, the list and review of the themes was built and, finally, the central theme was reached.
The management of change in health was used as a framework, which incorporates Kotter's three-phase approach (8) . Kotter's three-phase approach to change management is based on three distinct phases: creating a climate for change, engaging and empowering the organization, and implementing and sustaining the change. This health-driven model can be used from planning changes in the way to care for the patients to changes in the use of technologies to provide more safety and quality (8) .
During the analysis process, to confer credibility, consistency and confirmability, a discussion was held among the members of the research group, as well as feedback to the participants.

Results
Four community health agents, four nurses, three physicians, four dentists and two nursing technicians participated in the study. Of these, 15 (88%) were female and 2 (22%) male, with a mean age of 35 years old, ranging from 29 to 51 years old, 12 (70%) had complete higher education and five (30%) had complete high school, being active in the BHUs from 1 to 17 years, with a mean of 6.7 years of work.
To analyze the data from the interviews, the coded material made it possible to observe, in the organization of the statements, that the themes evidenced refer to the implementation process. Thus, there are four categories, namely: "Mandatory implementation. 'You have to implement'"; "Weaknesses for the implementation of the system"; "Fragile training to achieve implementation" and "Learning from the experience".

Mandatory implementation. "You have to implement"
In the PHC health units, institutional pressure to implement the e-SUS AB Strategy culminated in the implementation and mandatory use of the information system.

Fragile training to achieve implementation
The participants' narratives about the lack of sufficient and adequate training, before or during the implementation process, show doubts about how to use the e-SUS AB system in all its potential, lack of understanding of the Strategy purpose, as well as its relevance to PHC. In addition, attempts at training were reported; however, they were identified as insufficient to solve doubts, creating an impasse to register data in the new system.  [...] The person who explained to me how to use it was the previous doctor who was there. One day we were together here and she explained more or less how she uses it (ZPMED03).
Unlike the old information system, the SIAB, the e-SUS AB system allows for the interaction of the professionals due to its interface, which made decentralization of work possible, reducing the responsibility for the production of the team, as well as the burden on the nursing professionals, who, in their great majority, assumed the role of gathering the care records of the team and registering with the SIAB.  Even using parallel learning mechanisms, it is noted that the system is not implemented and that the information is used as an element of care qualification, but rather as accountability/justification for the managers.   Primary Care in Brazil (13) . In addition, the verticalization of policies and regulations (14) can contradict actions at the local level. In this case, such verticalization was permeated with mandatory and punitive aspects that reverberate mainly in the municipal sphere (15) , influencing the change management process.

Discussion
When it comes to change management, it is foreseen to set goals; however, just stipulating dates does not materialize processes. Lack of planning was evidenced when comparing the period of implementation in the municipality against the deadlines stipulated by the Ministry of Health to implement the e-SUS AB Strategy, initiated in August 2013, with its first deadline in July 2014, and the second deadline for December 2015, with an interruption in the transfer of funds scheduled from April 2016 (8,16) .
With support from the second Kotter's phase, the engagement and training of the professionals was evidenced by lack of ability to use the system due to the non-qualification of material resources that, in the perspective of the professionals, made the change process frustrating. In other settings, there was the same difficulty as for the qualification of the professionals for using the e-SUS AB system, such qualifications being determined as ineffective (17)(18) .
Considering international implementation experiences, training positively impacts on the professionals' experience, as well as on the knowledge to manage the implementation process and the transition between the systems (19)(20) . In addition to this, a study shows that using the aspects of change management, during the implementation of an electronic medical record, improves digital transformation in the health service (21) . www.eerp.usp.br/rlae 6 Rev. Latino-Am. Enfermagem 2021;29:e3447.
In an attempt to sustain the changes, as proposed in the third Kotter's phase, the professionals developed collaborative learning networks between team members and across the BHUs. Teamwork in health is considered as a way of relating within a group process, in which exchanges of knowledge and interests occur, forming a network of relationships among people (22) .
The learning mechanisms incorporated an exchange of knowledge between the professionals of the same team or in groups to share messages, being reported as fundamental for the use of the system and, consequently, for the development of the professionals' work during the beginning of data sending to the SISAB. In another study, carried out in Minas Gerais, collaboration was also evidenced between colleagues with the use of a group in a multi-platform of instant messaging related to the e-SUS AB system (15) .
It is worth reflecting that, even though cooperation for learning is a positive point, there are concerns regarding what is passed on among the colleagues, the diversity of manners to record the understanding on the proposal of the system for managing and qualifying care.
These factors can generate, respectively, inconsistencies and lack of integrity in the records entered by the professionals, in the electronic medical record, as well as affect the quality of the information (23) .
As a limitation of this study, the non-inclusion of the professionals on the commissions responsible for implementing it in the study scenario is highlighted, which would allow for an expanded understanding of this process. However, this study contributes as a management tool for the managerial bodies in the process of health change, such as the implementation of the e-SUS AB system and the impact on the daily lives of health teams.

Conclusion
There was an implementation process initiated with feelings of confusion and disappointment. Absence of vision, skill and resources can be evidenced, in addition to a harmful incentive process, conducted under the perspective of institutional pressure associated with the possible absence of planning. On the other hand, from the experiences and to meet the needs of the lack of ability to use the system, collaborative learning mechanisms were created.
These shared experiences can be directed in more assertive actions by the managerial bodies, given the implementation of the e-SUS AB system, with the improvement of user qualification, ensuring the necessary recourses for the infrastructure and support provision, aiming to guarantee the quality of the system, of the information and of the health service.
The periodic assessment on the situation of the implementation and use of the system in Brazil is necessary because, in addition to being an emerging reality, it can assist in improving the policies to achieve the objectives of the e-SUS AB Strategy and its national coverage.