Electronic Health Record: What Is NOM-024?

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The world is increasingly driven by technology and digital media. That is why every health facility must stay at the forefront of these changes in order to provide higher-quality service to patients. 

What Is NOM-024?

To adopt this way of working, it is necessary to comply with what the law establishes, and in Mexico's case, that means complying with Standard 024, also known as NOM-024.

It is worth noting that Mexico's NOM-024 has undergone several changes over time. In 2010, it established the importance of digitizing medical studies for better service to the population. Not only while in the hospital, but at any time, thanks to the creation of much more efficient electronic health records.

The benefits of using electronic systems that enable interoperability among public, private and social institutions and hospitals, as well as among physicians, are undeniable. All of this without overlooking the importance of this information being encrypted, being used correctly, and being available only to authorized personnel.

For its part, in its second edition, the 2012 version of NOM-024 placed greater focus on security in the exchange of medical studies. It emphasizes that the country's Health Service Providers must adhere to standards, definitions and catalogs in order to achieve the aforementioned interoperability.

In this sense, it is essential to understand the general aspects and requirements of this standard in order to make efficient and responsible use of information. On the other hand, more and more patients are demanding that the various products and services they use have digital backup that they can access whenever they want.

Current General Aspects of NOM-024 in Mexico

The first point refers to the obligation of health facilities to adopt Health Information Systems for Electronic Registries (SIRES). This allows the institution to exchange information with other facilities. This is highly valuable for detecting contagion threats to the population.

In addition, it emphasizes that these SIRES must ensure effective processing, security and interpretation of digital information, thereby safeguarding patients' integrity. In some cases, there may be disclosure exceptions as required by the State. All personnel at any health facility must be fully aware of these requirements, so that confidentiality is upheld at all times.

In addition to being a regulation, the above is part of the ethical and professional training that everyone providing services at a health institution acquires. It is therefore nothing new for physicians, nurses, and everyone else who has access to patient information. In the event of unauthorized non-compliance, they may face legal sanctions.

Now, regardless of the SIRES your health facility uses, the key is that it ensures exchange, integrity, electronic security in databases and servers, record traceability and efficiency.

PACS (Picture Archiving and Communication System) systems are therefore excellent technological solutions for any health facility to comply with NOM-024 regarding X-ray, MRI, CT, ultrasound images and other diagnostic modalities, as well as patient information.

Current Specifications of NOM-024

First, it should be noted that Mexico's Dirección General de Información en Salud (General Directorate of Health Information, DGIS) has formats and technical guidelines that health facilities must use. This helps staff understand how to exchange information with other institutions, so that all required patient and study data are included.

Some of the notable aspects in the aforementioned documents are the formats for text, diagrams, attachments and minimum required information. Examples include the structure of the digital document, data retrieval, image standards such as DICOM and text standards such as HL7, the applicable dictionary, and the bibliographic references of the reports issued.

What Should SIRES Take Into Account?

It is important that the Health Information Systems for Electronic Registries (SIRES) implemented to properly manage, safeguard and exchange information comply with formats, catalogs and standards that enable interoperability across the healthcare sector. A confidentiality and security system must also be implemented to prevent unauthorized disclosure or alteration of results.

To comply with the minimum data for identifying individuals, a record of each patient's general information must be kept:

• First and last name
• Address
• Sex
• Nationality
• CURP (Mexican unique population registry code)

It is also recommended that the technological solutions supporting SIRES include an advanced signature option, so that medical professionals can validate the information exchanged. Hence, it is essential to know which software is the best option for staying at the forefront of electronic media.

Electronic Health Record: Another Important Aspect

The Electronic Health Record, or ECE, is an essential function of SIRES, and relates to the safeguarding, archiving and accuracy of information. The purpose of this record is tied to the efficiency of the healthcare sector in Mexico, so that patients can have digital access to the history, information and clinical protocols for the conditions treated at health facilities.

This is how Hospital Information Systems (HIS) can hold a patient's complete information, including conditions, imaging studies, treatments, lab tests, insurance policies, and subsequent processes for that individual. This information must, of course, be governed by the communication standards and protocols required by NOM-024.

PACS Systems and the ECE

For all of the above to be possible, software has been created to feed into the HIS. In the case of radiology and imaging, there are PACS systems, which enable the management, storage, exchange and security of studies for practically all diagnostic modalities. These meet all the general and specific NOM-024 requirements mentioned above.

Eva PACS is a technological solution that meets all the requirements for health facilities, whether clinics, offices or hospitals. In addition to being accessible, it was developed together with radiologists, addressing all real-world needs, including compliance with these regulations.

If you would like more information or guidance on these topics, do not hesitate to contact an Eva representative.

References

• Secretaría de Salud (Ministry of Health) (2012). Norma Oficial Mexicana NOM-024-SSA3-2012. Second edition. [PDF Document]. 
• Secretaría de Salud (Ministry of Health) (2010). Norma Oficial Mexicana NOM-024-SSA3-2012. [PDF Document]. 

Electronic Health Record Manual. World Health Organization.