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Clinical information systems for the management of tuberculosis in primary health care

ABSTRACT Objective: to analyze the clinical information systems used in the management of tuberculosis in Primary Health Care. Method: descriptive, quantitative cross-sectional study with 100 health professionals with data collected through a questionnaire to assess local institutional capacity for the model of attention to chronic conditions, as adapted for tuberculosis care. The analysis was performed through descriptive and inferential statistics. Results: Nurses and the Community Health Agents were classified as having fair capacity with a mean of 6.4 and 6.3, respectively. The city was classified as having fair capacity, with a mean of 6.0 and standard deviation of 1.5. Family Health Units had higher capacity than Basic Health Units and Mixed Units, although not statistically relevant. Clinical records and data on tuberculosis patients, items of the clinical information systems, had a higher classification than the other items, classified as having fair capacity, with a mean of 7.3 and standard deviation of 1.6, and the registry of TB patients had a mean of 6.6 and standard deviation of 2.0. Conclusion: clinical information systems are present in the city, mainly in clinical records and patient data, and they have the contribution of professionals linked with tuberculosis patients.


Introduction
Tuberculosis (TB), an infectious disease considered a serious global public health problem, is a reflection of social and economic inequalities and has had major impacts on the morbimortality of the population, especially in the most vulnerable segments of developing countries (1) . This is reinforced by data from the World Health Organization showing that TB is among the ten leading causes of death in the world and that in 2015, 10 million people became ill and another 1.8 million people died due to this disease (2) . TB deserves special attention also because of the high number of people living in the world as carriers of the disease, but who are not notified and contribute to the dissemination and transmission in the community (3) .
Brazil ranks 18th in the absolute number of TB cases accounting for 0.9% of estimates in the world and 33% in the Americas. On average 70,000 new cases were diagnosed and approximately 4,400 deaths per year were reported from 2005 to 2014 (4) .
As a way to reduce these indicators, the National Program for TB Control was created with the proposal of implementation of prevention, control and treatment actions for health surveillance of the TB cases in a horizontal and decentralized manner. Given this, Brazil has presented important data of reduction of incidence and mortality rates due to this disease (5) .
Its implementation is carried out mainly through the Primary Health Care (PHC), a complex and resolute strategy with the capacity to coordinate the Health Care Networks that, in this scenario, is organized through the Family Health Strategy (FHS). This strategy proposes the reorientation of the assistance model through the provision of teams that meet the needs of the population in the territory (6) .
For this, multiprofessional work and the creation of bond between these professionals and the population is necessary to allow the development of strategies of access, prevention and treatment of the disease. Such activities are possible when these professionals make use of the registration of important information about the health conditions of the users of the services (7) .
Clinical information systems in the health area are assistance instruments that allow the recording and analysis of data, so that professionals can relate health problems to their determinants, identify the risks of disease involvement, carry out the follow up, idealization and realization of prevention and treatment actions, so as to improve the quality of life of patients (8) .
Based on these findings and understanding the importance of the development of these systems in the scenarios of clinical performance, the question is: how are the clinical information systems used to treat TB in PHC?
To answer this question, the present study aims to analyze the clinical information systems used in the management of TB in PHC.

Methods
A cross-sectional, descriptive and quantitative study was carried out with professionals from PHC units in a Brazilian northeast capital.
This study considered as Basic Health Unit (BHU), the one that provides care for spontaneous or programmatic demand of the population without the In case of refusal to participate in the study, other health professionals would be selected, provided they met the above criteria. Thirty-two professionals refused to participate in the research, being 17 physicians, one nurse, 12 nursing technicians/assistants and two CHA. use health services. It is also considered an aspect of effective care models that use population approaches (9) .
In this dimension, information about the capacity of the city, of the health units, of professionals and of the clinical information systems used for the management of TB patients were analyzed.
These items were classified according to their capacity to provide care, according to the following criteria: limited capacity (between 0 and 2), basic capacity (between 3 and 5), fair capacity (between 6 and 8) and optimal capacity (between 9 and 11).  Table 1.  Regarding the items that make up the clinical information system, shown in standard deviation of 1.6) and registry of TB patients (mean of 6.6 and standard deviation of 2.0).  This will help to follow the evolution of the treatment of patients. The adequate filling of the records is a responsibility of the whole team (11) .

Discussion
The registry of TB patients also presented a fair classification. The importance of this registry for the TB control program comes from the fact that the information A study conducted nationwide in 2016 showed that 43.6% of the health units did not have a registry of TB patients and 49% of these units did not know or did not answer the question regarding the follow-up registry of TB cases (12) .
Research demonstrated the importance of using better therapeutic adherence. This is possible through the systematization of services by the provision of DOT actions, TB guidelines, incentives to conduct tests, program improvement, among others (13) .
The fact that, in the present study, notices and reminders to health professionals about the occurrence of new cases had a basic character points to the difficulty in guiding TB control actions, because the lack of knowledge of the health situation of assigned territories make it impossible to create successful strategies (14) .
Regarding the basic character of the feedback of information, a study found similar results (9) . It is obvious that this aspect detected in the study make it difficult to plan interventions, as health professionals are unable to monitor and evaluate the control actions. Consequently, the health team becomes only the recipient of information and not a participant in the process of providing care for TB patients (15) .
Regarding the basic classification of the item information about TB patients at risk of abandonment, failure and death, this situation suggests the need for greater attention on the part of professionals, because, as observed in the study, neglect of information on treatment abandonment and other situations are a reson of concern for the control of TB (16) .
One of the main obstacles to the control of TB is the abandonment of treatment; it has an impact both on the increase of the cost of treatment, and on the mortality and relapse rates. It is also observed that this lack of adherence may increase the spread of the bacillus, and also its resistance. This is especially true among young people with low schooling, alcoholics and people with mental illness. Strategies to encourage treatment adherence among this publics are necessary (17) . This organization has elements that can strengthen the bond between professionals and patients, and the health team itself. This is because the internal organization of work in the health unit, through the management of TB control policies and programs by all those involved in the management of the case, enables the dissemination of knowledge about the patient, and the generation of relevant and indispensable information to the reference system, when necessary (9) .
As a way to expand this care and obtain better results regarding the availability of information on the treatment of TB carriers in PHC, the constant training of professionals and access to quality information materials, as pointed out in the study, it is recomendable (19) .
The continuous stress of the important roles of these professionals in the control of TB is also one of the ways to achieve the effective dissemination of information on TB treatment.
Regarding the limitations to the accomplishment of this study, we highlight the difference in the number of professionals in the professional categories, which made data collection difficult, and the inferences to the population, through these categories, impossible.

Conclusion
The clinical information systems in the city presented fair capacity, and nurses and CHA were the professionals that contributed the most to these results.
On the other hand, physicians and nursing technicians/ assistants had basic capacity in the use of these systems for the clinical management of TB.
The data showed that FHU were presented better classification when compared to the others units, which is mainly due to the fact this units offer a care that allows a greater bond between professionals and users, which in turn contribute to the better use of the information.