innovations in Primary Health care : the use of communications technology and information tools to support local management

Social media has been used in different contexts as a way to streamline the flow of data and information for decision making. This has contributed to the issue of knowledge production in networks and the expansion of communication channels so that there is greater access to health services. This article describes the results of research done on 16 Information Technology and Communications Observatories in Health Care OTICS Network in Rio covering the Municipal Health Secretariat in Rio de Janeiro which supported the integration of primary health care and promoted the monitoring of health. It is a descriptive case study. The results relate to the support given to employees in training covering the dissemination of information, communication, training and information management in primary health care. This innovative means of communication in public health, with very little cost to the Unified Health System (SUS), allowed for a weekly registering of work processes for teams that worked in 193 primary health care units (APS) using blogs, whose total accesses reached the seven million mark in mid-2015. In the future there is a possibility that distance learning tools could be used to assist in training processes and in the continuing education of professionals in family health teams.


introduction
The use of new information technology and communication tools in health has been increasing over the last decades with the advent in the use of email and social media.These innovations have helped to streamline the flux of data and information for decision makers in management.It has also contributed to the production of knowledge in networks and the widening of communication channels so that there is greater access to health services 1,2 .Various experiences that have involved combining and integrating the use of digital tools are now being consolidated through the "Public Health Observatory".They are being enhanced and are regularly updated.
Ferreira 3 gave a better and modern definition of a Public Health Observatory by stating: […] apart from being centers that conduct analysis, they are also unhindered structures for receiving communications (which assist in informing, supporting and evaluating the taking of decisions and for intervening at local levels).They are also useful for issues outside of the health care sector (advocating health care and influencing public policies that have the most amount of impact on health).
Having conducted a revision of the literature written by this author, she notes that in general there are national and regional structures that were created as a result of strategic decisions taken by key managers that held government positions.They are financed, in part or completely, by the Government.When they are created to cover regions, they work with the expressed function ofbeing "networks" and form part of the daily work that is undertaken.They allow for observation and critical analysis in the progression of state health care indicators in a continued and systematic way.These indicators cover the population in general or a specific sub-population and it brings together multidisciplinary teams and specialists in specific areas with the view to identifying and analyzing realities, contexts, facts and processes.
The historical analysis of the Health Care Observatories in central and south America revealed that there was the option to focus on the management of health care professionals or the health of those that work in health care 4,5 .
In Brazil, a possibility raised by Pinto 6 who was one of the authors to bring this multifaceted approach, referred to the use of a group of indicators to monitor the health system and service.The monitoring includes: geographical space from the micro to the macro, a census conducted in the sector, micro-areas for family health care teams, boroughs, districts, municipalities, and any other regions of interest.These demographical indicators which cover socioeconomics, mortality, morbidity relating to identified risk factors and associated coverages and resources (physical, human and financial) all can be instrumental for use in research forms 7 .The above areas when analyzed, help in understanding and interpreting the potential for health care indicators.The approaches can, by their very nature, be long and transversal.
In Europe the approach has been to compare health services and systems particularly looking at the communication process in primary health care.Attention is also given to social, economic, environmental, mortality and inequality indicators in health 4 .

Health Observatories: Health care in europe
The European Observatory for the Systems and Policies in Health is coordinated by the Regional Office for the World Health Organization (WHO).It is a partnership which includes the following countries, regions and bodies: Austria, Belgium, Finland, Ireland, The Netherlands, Norway, Slovenia, Spain, Sweden, the United Kingdom, the region of Veneto in Italy, The French National Union for Safety and Security in Health (UNCAM), the European Commission, the European Bank for Investment, the World Bank, the London School of Hygiene & Tropical Medicine (LSHTM) and the WHO.It promotes good health based on evidence from an all-encompassing and rigorous analysis of the dynamics of the health systems in Europe.This directly involves public sector managers.It acts in partnership with researchers, research centers, governments and international organizations.Its values include the following: research done for the benefit of the population, excellence, integrity, accountability and a guarantee that the analysis of the data that is carried out will not discriminate against any social, ethnic, cultural and religious groups 8 .It supports and finances comparative research done between different health care systems in Europe and developed countries outside of Europe which was the case in the classic example of Saltman et al. 9 .They analyzed primary health care and organizations in this area with other health systems with a view to improving the results in a country.They also sought to understand how new technology could be integrated at a certain level in the health system.
Hemmings & Wilkinson 10 described the National Network of Regional Observatories in Public Health created in England, in 1999, whose objective was to reinforce the availability and use of information about health at a local level in every regional health system in the country.Initially, the Observatories were connected with universities in order to provide academic rigor to the work.Its main task would be to support local bodies in: monitoring health and illnesses, identifying lacunas in the information on health, giving guidance onrecommendable health methods and evaluating the impact of health inequalities.It would also aim to trace and detect, early on, possible future problems in public health 11 .
This Observatory Network based itself on the first Observatory that had been in existence when the government decided to create a National Network: the Liverpool Public Health Observatory, created in the 1990's.This Regional Observatory can be analyzed in our present time and it produces the most amount of information in this area which is subsequently disseminated in England.It also produces tools for conducting scientific research in public health 12 .Some of the areas that have been studied include: family planning, fertility and abortion, coronary diseases, services to rehabilitate drug users and alcohol abusers, asthma and environmental pollution, environmental causes of death or incapacity to work, tuberculosis and poverty.
In 2014, there were twelve Regional Observatories in Public Health in the United Kingdom.Amongst these, nine coordinated their activities together in England based on a work plan that contain both national and local objectives.They produce information, data and intelligence for decision making processes.This is for managers working in health care to help populations in specific areas.These structures moved to being integrated in the Department for Health in the Government and from the 1st of April 2013 it would be managed by one of the executive agencies of the Health Ministry -Public Health England.
The Health Observatory for the City of London 13 produced information on the 7.8 million inhabitants that lived in this city and it developed training programs for health care professionals from all of the Regional Observatories.It also acted in partnership with national government agencies.It leads the way in thematic areas such as inequalities in health and studies on smoking.
It also serves as a center of excellence for all the other Regional Observatories.
The Yorkshire and Humber Public Health Observatory (YHPHO), that was created in 2004, also produces information, data and intelligence to support the decision making process for managers in health care forspecific populations in a given area.It conducts its work through partnerships with the following: the NHS, local health and safety authorities, researchers and national agencies.The thematic areas that it works in includes: diabetes, the health economy, and the health of children, teenagers and women.It is physically located at the University of York on campus 14 .
On the other hand both the Eastern Region Public Health Observatory (ERPHO) and the North East Public Health Observatory (NEPHO) work in the following thematic areas: infectious diseases and environmental risks (such as radiation and risks in relation to chemicals and poisoning) 15,16 .
In 1999 the Portuguese Observatory for the Health System (OPSS) was created and was connected with the National School for Public Health at the New University of Lisbon in Portugal.Sakellarides 17 , who coordinated the creation of this Observatory, stated at the time that "the creation of a Portuguese observatory for the health system will allow for continuous, prospective, interactive and pedagogical analysis of the development of the Portuguese health system.It will provide a valuable contribution from investigative and teaching institutions in the country to overcome the current situation".
Barbosa 18 analyzed the OPSS and highlighted the contribution it made to the European Observatory for Health Systems of the WHO in promoting the creation of inter-institutional networks that analyze certain areas.Aside from providing external contributions, this observatory had as one of its objectives to analyze the prospects of Portugal's health system.It would publish periodically, conjuncture reports on its institutional page such as the "Spring Report 2013" 19 .Aside from this, the Observatory has been contributing, throughout the years, to the analysis of the Portuguese National Health System which is a part of the Portuguese Health Ministry.This has been done through direct and indirect administrative bodies in which can be found five regional health administrations and public companies 20 .
The Regional Health Observatory for Alentejo was created by the Regional Health Adminis-tration/Health Ministry to follow and monitor the complaints, suggestions and thanks given by health care service users of the national health system.It was also to follow decisions made, that related to it.It does the following: it makes available to the public information on public health, it publishes indicators that allow for the evaluation of service users' satisfaction and participation in relation to the care that they have received and it develops training programs for health care professionals in the region.However on closer inspection of their Portal it was noted that no use was made of local databases in their own studies or in partnership with other bodies.This indicated that it is an "Observatory" that does not produce data from primary or secondary sources to be analyzed.It limits itself to making available material and other institutional information from local health administrations and its serves as a large virtual library in local health 21 .
The Regional Health Observatory in Lisbon and the Tejo Valley covers an area called "Greater Lisbon".According to Quitério et al. 22 "Greater Lisbon" is made up of nine councils and the Lisbon Council has 24 parishes.In the areaof health, this Council in 2012 was re-divided into three Health Care Center Groups (ACES) with eighteen health units: North Lisbon (with four health centers), Central Lisbon (with nine health centers) and West Lisbon and the Oeiras Council (with five health centers).In terms of comparisons of the geographical administrative divisions that exist in Brazil, the "Greater Lisbon" area would correspond to a "Metropolitan Region".The Lisbon Council would correspond to a "municipality" and every parish would be equivalent to a "borough" or "district" (sub-division of the municipality).
This Observatory was created by the Local Regional Health Administration/Health Ministry to provide support in reaching the Millennium Development Goals in thematic areas such as: nutrition, infant health, maternity health, reproductive health, immunization, HIV/AIDS, tuberculosis and water sanitation.The researched indicators included: mortality, the burdens caused by illnesses, transmissible and non-transmissible diseases, risk factors, environmental health, violence and equity.Its objective included publishing a tranche of information through the integration of existing knowledge on risk factors and their effects on health.This would allow for a better understanding of problems and an analysis of health situations in the health center groups.With this information, support would be given in the drafting of a Regional Health Plan which would improve the communication of risks to populations.It would also lead to the integration of knowledge and innovation, contributing to the social and economic development of the country 23 .One of the main contributions was the consolidation of the "Profile Report on the City of Lisbon and its outskirts" 24 and the "Health Picture in Lisbon" 22 .
The Regional Health Observatory for the Isle of France (ObservatoireRégional de Santé Île-de-France) was created in 1974 with the support of the Mayor's office and subsequently became the Technical Department for the Development and Urbanization Institute for the Paris Region (IAURP).The region of the Isle of France is composed of eight departments.Many times the region is confused with the Parisian Agglomeration whose area accounts for only 20% of the Isle of France region.However there is a 90% concentration of the population in this region.
Its goal is to support the local management of publichealth care receiving finances from a regional council and the Regional Health Agency in the Isle of France 25 .This observatory observes, follows, analyzes and informs on health issues.On an annual basis it drafts its work plan with its local partners, including scientific institutions and financiers.It participates in the drafting of different regional public health plans.It also does the following: carries out studies in relation to local demand, analyzes health problems relating to regional programs and it seeks to understand social determinants and inequalities in areas that it covers.It conducts studies on people's perceptions and behavior in relation to prevention.It follows the development of trends over a period of years.
Aside from the above it studies various life cycles and conducts analysis on morbidity and mortality.It also conducts analysis into behavior with reference to the use of drugs, tobacco, alcohol and life styles (covering nutrition, sexuality, and contraception) and environmental health.Its methodologies include: qualitative and quantitative approaches, cross-referencing and evaluating data, carrying out surveys and putting together socio-sanitary and geo-referencing indicators for events 25 .
Other European countries also utilize similar strategies, some of which cover the national ambit whilst others are regional.In Spain the National Health Observatory System is an organ dependent on the Health Ministry and it conducts continuous analysis of the National Health Care System through studies where comparisons are made with health care in the Spanish autonomous communities in relation to the organization.The studies also cover the provision of services and the management of sanitation.It also drafts an Annual Report on the National Health System 26 .In the regional ambit we can highlight the Public Health Observatory of Cantabria (OSPC) which was created in 2006 as an information, analysis and investigation unit on the health situation of this region located at the extreme north of Spain 27 .Its ultimate aim is to produce relevant information for policy makers, managers, researchers, health care professionals and the public in general in order to improve policies, programs and services.These policies, programs and services should meet health needs in both an equitable and efficient manner and should reduce health inequalities in Cantabria 27 .
The Health Observatory for Asturias (OBSA) -an autonomous community and a province of Spain which is also located in the extreme north of the country -is a project developed by the Director-General for Public Health in the Astúrias Government in collaboration with the Population Health Institute of the University of Wisconsin which "deals with generating information, conversations and actions" 28 .One of the objectives of the Observatory, that was founded in May 2011, is to provide information on the health situation in the region and its municipalities through the use of succinct performance indicators in health (covering the health system, management, socio-economic factors and the environment) and covering its performance record for health care 28 .
Following from the above brief revision of the literature on some of the most important observatories in public health in Europe, we can highlight some possible areas for analysis that have been utilized in various countries and regions: 1) monitoring the health status of populations and sub-populations and identifying their health needs, 2) integration of the various databases of interest in health into one large repository for future analysis ('big data'), 3) carrying out epidemiological monitoring of transmissible diseases and non-transmissible diseases in the ambit of environmental health, 4) monitoring and evaluating the effects and impacts of the performance of the health programs and services with a view to seeing improvement in health and a reduction in inequalities in health, 5) carrying out and supporting operational and applied research utilizing the capture and collection of data which includes data from the internet, 6) sharing, in networks, the production of knowledge that is generated, 7) proposing adequate recommendations and providing information to target audiences (public health reporting), 8) thedissemination and periodic updating of results on relevant social media platforms in the required format, 9) utilizingsecondary data sources and other databases produced by the National Institute of Statistics, Health Ministry, and specific regions for each country.
Therefore the purpose of this paper is to describe the results obtained based on the implementation of the local Observatory Networks by the Municipal Secretariat for Health in Rio de Janeiro covering ten planning areas in health in the city.

the Network of Observatory Stations for Health services in the Planning areas in the city of rio de Janeiro
The Network of "Observatory Stations for Information Technology in Health Care in the City of Rio de Janeiro" (OTICS-RIO) is a partnership with the Municipal Secretariat for Health in Rio de Janeiro (SMS-RJ) and various academic institutions.The Network has the vision of "being a reference for SUS in Rio de Janeiro for strategic training projects and for the provision of support in the Sub-secretary's network that covers Primary Health Care, Monitoring Health and the Promotion of Health -SUBPAV" 129 -for ten planning areas for health in the city.Its mission is to promote the integration between extension actions and health education on primary health care services, the monitoring and promotion of health and in particular to support the actions in the Core Support Networks for Family Health (NASFs).Its main values are: information in real time, interactivity, professionalism, simplicity, transparency, solidarity in networks, innovation, and focusing on results.The Network is made up of sixteen stations divided amongst ten planning areas in the city of Rio de Janeiro.Its implementation consolidates what is produced by the Family Health Teams on social media through blogs with periodic maintenance by health care professionals whohave been doing this work since 2011.It also allows for the analysis of strategic consolidated indicators through using the electronic patient reports used in primary health care known as -"Tabnet-Ficha-A", launched through the Network 30 .Also the whole process of outsourcing is mapped by health teams covering families and micro-areas.They were built by community health agents and are validated by the other members in the team as well as other local managers 31 .
The With these spaces there was the creation of a virtual space -a Portal -that had two implemen-tation phases: one that started in 2010 with academic support and the other started in 2011.In the second phase the Stations were organized to form a station portal called Network OTICS-RIO (Figure 1) which was developed by SMS-RJ to deal with the increasing expansion of the health units for each one of the ten APs.
This new directive requiring the maintenance of the Network by SMS was essential for ensuring daily updates of their social media in the AP and for decentralizing actions for the planning areas.The professionals that work in the stations in the "local Networks" started to train and increase their knowledge that had been developed in workshops with professionals from the Family Health Teams in their bloggers' training at APS. However the partnership with the teaching staff and researchers that had been in place since 2010 (the first phase of the Project) was maintained as a way of enriching the blogs adding different perspectives and innovations for primary health care.Nevertheless from 2011 the Network switched to being "real" (physical spaces called "Stations") and "virtual" (a portal for the network with blogs, twitters, and Instagram for every station) presenting solutions and knowhow in the form of continuous education and in- tegration with primary health care actions.This also included the monitoring and promotion of health and allowing the users (from different places) to get a glimpse of the day to day work of the Family Health Teams in the city of Rio de Janeiro.Finally, according to Ramalho 32 "social media gives a voice to millions of people to express their opinions and experiences to a global audience at zero cost or close to this".

results of the use of social media in primary health care
In city of the Rio de Janeiro, 860 Family Health Teams and 346 Oral Hygiene Teams were active in May of 2015, according to the data from the National Register of Health Establishments (CNES) from the Health Ministry 33 .
Through 2014 of the stations were institutionalized by the SMS-RJ based on their register from the CNES.They also started to do educational activities for the promotion and the monitoring of health.On a monthly basis they were then informed of their SIA-SUS code which needed to be shown at outpatients units.In 2014 15,782 promotion and monitoring actions were undertaken on health (Table 1): From 2011 to 2013 the main actions that were undertaken and the results that were obtained can be grouped into three main starting objectives, that were planned as part of the Network concept between 2009-2010: (i) support in the training of SUS staff, (ii) support in providing information on health, (iii) support in the organization and management of information in primary health care (Chart 1).
Based on the development of the Network team that was decentralized and placed in all of the planning areas, it was possible to consolidate 193 semi-institutional blogs that were created after training workshops for bloggers had been conducted in the primary health care units on at the stations.A free hosting tool was used on the internet.Approximately seven million accesses to the blogs were made up until May 2015 (Table 2).The fact that the residents in the areas that were covered in every community accessed the blogs, is an indirect indication of the communication carried out on a daily basis between the public bodies and the citizens.Social media allows all types of information to be made available covering: opening hours, telephone contact details, details of the catchment area, and a list of health actions/activities in every Municipal Center for Health and Family Clinics at the Primary Health Care Units.
The blogs try to encourage good practices for communication and the provision of infor-mation to the population so that the minimum content is placed in categories and there is a standard layout and format.This is done through a blog competition for Family Health in SUS that Source: All of the above was done based on initial actions that were approved by the SMS-RJ in 2010 and the results were observed between 2011-2013.Production and availability of multiple channels of communication -twitter network, primary health care blogs, audio-visual productions, virtual areas for collaboration on the environment with downloads and uploads, that aid in the exchange of information and communication in health during the work process for the Family Health Teams.This also covers other areas of interest such as monitoring and promoting health.Results: a) 2,7 million accesses to the Stations' Blog Network (meaning 600,000 international accesses from the United States, Portugal, Germany, Italy, England and France).From 2013 gadgets allowing for translations to other languages to be done for every blog, was included in the Station Network b) 190 blogs covering the Family Health Strategy support by a similar number to the primary health care units c) 152 short films on thematic areas (available at the YOUTUBE account @ SMSDCRJ @OTICSRIO) d) 48 twits of support for actions promoting health, vaccination campaigns and other specific health days.e) RIO-SUS GUIDE (10 volumes, with general data on every primary health care unit in a directory containing their addresses and other information.)Action: Production and organization for the monitoring and evaluation of performance indicators for the primary health care units, in particular covering the electronic patients' records (socio-demographical indicators and it covers morbidity).Results: a) Books with statistics and maps for the primary health care units (CEMAPS-RJ, 10 volumes, with maps for micro-areas/teams/units and information on all of the Family Health Teams) b) Monitoring of the quality of how the registers are filled in, which is Form A (the "Tabnet" tool for appointments) from the Family Health Teams ("management of the list of duplicate registers").c) Research on opinions with staff from the Municipal Centers for Health and Family Clinics (n=13.973,69.1% of the total, collection of data online in five days) was launched by the Municipal Secretariat for Health and which identified the best blogs in different categories: (1) The best schedule available in real time, (2) Find out more about us by ACS, (3) How do I do…? (4) The best photograph, (5) The best short video film, (6) The Rio Academic Program, (7) Youth Protagonist, (8) The best photographic coverage, (9) The best audio-visual coverage, (10) The best content (11) The best interactivity, (12) The best creativity (13) Health in Schools, ( 14) The best integration between teaching-service-community, (15) The best integration between monitoring and Family Health and ( 16) The best blog.

N° access to blogs
The other tool that can be used for the management of content on social media in primary health care is the "word clouds" 34 .It helps in the consolidation of a large volume of text, questionnaires and other surveys for management, which allows for thematic analysis similar that which has been done by Bardin 35 .

Final considerations
The Health Observatories were developed with the aim of widening and making available information and evidence for making decisions in the health field, which includes the following areas: monitoring health care, the promotion of health care, analyzing primary health care, and the management of education in health.The importance of the observatories is related to the information that is available.It is also related to the possibility of producing analysis that covers monitoring and evaluating data and observing tendencies.Aside from this, with the use of technology, the observatories continue to provide regular and ongoing updates and they allow for interactions and collaboration to take place between different interested parties.
In relation to the OTICS-RIO, this form of innovative social communications done at very low running costs for SUS and with the use of information technology, allows for the capturing of day to day work in an easy and modern manner for every health unit.It also allows for access to be made in real time of documents, videos, photographs and other means of registering information which can then be subsequently shared with society.It also facilitates the exchange of experiences and it allows for the institutional recognition of best practices.Over the last five years the creation of such cultural organizations has allowed for the incorporation of work processes for the ESFs and for the regular updating of blogs in every unit which serves as a principal communication channel for populations in specific catchment areas.From 2014 the directors and managers of every unit became responsible for validating the content of the blogs and they featured as part of the discussions and weekly meetings.
The main limitation of the OTICS-RIO Network is the lack of integration with some of the Study Centers that concern planning which only focus on supporting the educational development of students through internships and extra-curricular activities on graduate courses partnering the SMS.It fails to follow, in a timely manner, innovations that are implemented in health units.
One of the aims for the Observatory Network OTICS-RIO is: to have a virtual environment for learning (AVA) with tools that permit distance learning.This should allow for the analysis of information and the measuring of educational achievements of health care professionals in permanentor continuous education.The following has been taken into consideration: the constant flux of professionals in the Family Health Teams, the potential of the OTICS-RIO Network through the use of distance learning and the sharing of multimedia content.
Finally it should be noted that the Brazilian Society for Family Medicine and the Community collaborations Pinto LF and Rocha CMF participated in the idea through defining the scope of this paper.They also contributed to: the drafting, the analysis of the data and the production of the final paper.recognize the use of "blogs" as a tool for communication in health care for Family Health Teams (ESF).They invite teams from the OTICS-RIO to participate in video workshops and they divide their work into territories for primary health care.Also blogs were drafted at their last national scientific congress that took place in the city of Belém 38 and Gramado 39 .Territorial workshops allow community health teams to revise and consolidate micro-areas that fall under their remit of responsibility and it supports local management in redefining new territories aside from those that are near to the health workers and stimulate discussions on integrations with the APSs.
physical spaces for the stations -"the Information Technology and Communication Observatories for Health services" -in the city of Rio de Janeiro came about as a response from the SMS-RJ to the need for quality welcoming structureshaving the capacity for 27 student terms on the Training Program for Local Agents that monitor health (PROFORMAR) from Fiocruz, in 2009.This large scale training program which had 1,392 places that were initiallyoffered, concluded its training program in 2011.The current state of play is that the Station consists of a physical space in a health municipal unit.It has: an auditorium, a teaching/reading room, an information technology laboratory and an academic secretary.

Figure 1 .
Figure 1.The Stations Network for the Observatory for Health services in Planning Areas in the City of Rio de Janeiro, available at http://www.redeoticsrio.org/.

chart 1 .
Network of Stations OTICS-RIO: objectives, actions and main results achieved, Municipal Secretariat for Health, Rio de Janeiro, 2011-2013.network of SUS staff in primary health care (APS), in particular providing support at their physical spaces with activities from the Core Family Health team (NASF) Results: a) 1,195 meetings/workshops/courses/training groups/seminars carried out in the presence of 44,894 people circulating in the stations between 2011-2013.b) Support for specialist courses, professional Masters, updating skills courses and technical courses for Community Health Workers and Local Health Monitoring Agents Action:

table 1 .
Stations that are a part of the Observatory Network and productions which are registered Municipal Secretariat for Health, Rio de Janeiro, 2014.

Stations that are a part of the Network *
Source: SIA/SUS, available at: http://www0.rio.rj.gov.br/cgi-bin/dh?sia/definicoes/producao_2008.def,access in May 2015.* The name of every station with the borough in which it is located next to the municipal health unit and their description can be seen at: http://www.redeoticsrio.org/.** The Station was opened in December 2013 and it only started its work from July 2014.

table 2 .
Distribution of the primary health care units per year covering their opening, implementation of the Family Health Strategy, the number of teams and the number of accesses to unit blogs, according to the Planning Areas for Health -Municipal Secretariat for Health, Rio de Janeiro, May 2015.
Family Clinic, CMS A = Municipal Health Center that only has ESF, CMS B = Municipal Health Center that has the mixed model (with ESF and other specialists), CSE = Health School Center.ESF = Family Health Teams, ESB = Oral Hygiene Teams