Disadvantages of Spreadsheets – Obstacles to Compliance in the Healthcare Industry

Most of the regulatory compliance issues we talked about concerning spreadsheets have been related to financial data. But there are other kinds of data that are stored in spreadsheets which may also cause regulatory problems in the future.

In the US, a legislation known as HIPAA or Health Insurance Portability and Accountability Act is changing the way health care establishments and practitioners handle patient records. The HIPAA Privacy Rule is aimed at protecting the privacy of individually identifiable health information a.k.a. protected health information (PHI).

Examples of PHI include common identifiers like a patient’s name, address, Social Security Number, and so on, which can be used to identify the patient. HIPAA covers a wide range of health care organisations and service providers, including: health plan payers, health care clearing houses, hospitals, doctors, dentists, etc.

To protect the confidentiality, integrity, and availability of PHI, covered entities are required to implement technical policies such as access controls, authentication, and audit controls. These can easily be implemented on server-based systems.

Sad to say, many health care organisations who have started storing data electronically still rely on spreadsheet-based systems. Those policies are hard to implement in spreadsheet-based systems, where files are handled by end-users who are overloaded with their main line of work (i.e. health care) and have very little concern for data security.

In some of these systems, spreadsheet files containing PHI may have multiple versions in different workstations. Chances are, none of these files have any access control or user authentication mechanism whatsoever. Thus, changes can easily be made without proper documentation as to who carried out the changes.

And because the files are normally easily accessible, unauthorised disclosures – whether done intentionally or accidentally – will always be a lingering threat. Remember that HIPAA covered entities who are caught disclosing PHI can be fined from $50,000 up to $500,000 plus jail time.

But that’s not all. Through the HITECH Act of 2009, business associates of covered entities will now have to comply with HIPAA standards as well. Business associates are those companies who are performing functions and services for covered entities.

Examples of business associates are accounting firms, law firms, consultants, and so on. They automatically need to comply with the standards the moment they too deal with PHI.

More Spreadsheet Blogs

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Disadvantages of Spreadsheets – obstacles to compliance in the Healthcare Industry

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Still looking for a Way to Consolidate Excel Spreadsheets?

Disadvantages of Spreadsheets

Spreadsheet woes – ill equipped for an Agile Business Environment

Spreadsheet Fraud

Spreadsheet Woes – Limited features for easy adoption of a control framework

Spreadsheet woes – Burden in SOX Compliance and other Regulations

Spreadsheet Risk Issues

Server Application Solutions – Don’t let Spreadsheets hold your Business back

Why Spreadsheets can send the pillars of Solvency II crashing down

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Eck Industries Sheds Fresh Light

William Eck began his business in 1948 in a 650m² garage building. The aluminium foundry prospered, and now has an 18,500m²factory in Manitowoc, Wisconsin employing 250 people casting a variety of casings. Like high-tech industries around the globe it needs effective illumination. After it measured its carbon footprint, it realised it needed energy efficient lighting too.

When Eck Industries began its review it had around 360 high-pressure sodium lights throughout the plant. Their operating cost was substantial. After taking independent advice from an independent agency they realised they needed to replace these with more energy-efficient fluorescent lights that consume half as much energy.

The feasibility team conducted performance tests to determine the optimum solution. After selecting enclosed, gasketed and waterproof T8 fluorescents (available in G13 bipin, single pin and recessed double contacts) they collaborated with the supplier to calculate the best combination of 4 and 6 bulb fixtures.

The fittings they chose cost $60,000 plus $10,000 installation. However a $33,000 energy rebate wrote down 47% of this immediately. They achieved further energy savings by attaching motion sensors to lights over low-traffic walkways.

The retrofit was a huge success, with an 8 month payback via a direct operating saving of $55,000 a year. Over and above enhanced illumination Eck Industries slashed 674,000 kilowatt hours off its annual lighting bill. During the 20 year design life, this equates to a total 13.5 million kilowatt hours. Other quantifiable benefits include 443 tons less carbon, 2 tons less sulphur dioxide, and 1 ton less nitrogen oxide per year.

Many companies face similar opportunities but fail to capitalise on them for a number of reasons. These may include not being aware of what is available, lacking technical insight, being short of working capital and simply being too busy to focus on them.

Eck Industries got several things right. Firstly, they consulted an independent specialist; secondly they trusted their supplier to provide honest advice, and thirdly they accepted that any significant saving is worth chasing down. Other spin-offs were safer, more attractive working conditions and an opportunity to take their foot off the carbon pedal. This is an excellent example of what is possible when you try.

If you have measured your illumination cost and are concerned about it (but are unsure what the metric means within the bigger picture) then Ecovaro offers online reports comparing it with your industry average, and highlights the cost-benefits of alternative lighting.

2015 ESOS Guidelines Chapter 3 to 5 ? The ESOS Assessment

ESOS operates in tandem with the ISO 50001 (Energy Management) system that encourages continual improvement in the efficient use of energy. Any UK enterprise qualifying for ESOS that has current ISO 50001 certification on the compliance date by an approved body (and that covers the entire UK corporate group) may present this as evidence of having completed its ESOS assessment. It does however still require board-level certification, following which it must notify the Environment Agency accordingly.

The Alternate ESOS Route

In the absence of an ISO 50001 energy management certificate addressing comprehensive energy use, a qualifying UK enterprise must:

Measure Total Energy Consumption in either kWh or energy spend in pounds sterling, and across the entire operation including buildings, industrial processes and transport.
Identify Areas of Significant Energy Consumption that account for at least 90% of the total. The balance falls into a de minimis group that is officially too trivial to merit consideration.

Consider Available Routes to Compliance. These could include ISO 500001 part-certification, display energy certificates, green deal assessments, ESOS compliant energy audits, self-audits and independent assessments

Do an Internal Review to make sure that you have covered every area of significant consumption. This is an important strategic step to avoid the possibility of failing to comply completely.

Appoint an Approved Lead Assessor who may be internal or external to your enterprise, but must have ESOS approval. This person confirms you have met all ESOS requirements (unless you have no de minimis exceptions).

Obtain Internal Certification by one of more board-level directors. They must certify they are satisfied with the veracity of the reports. They must also confirm that the enterprise is compliant with the scheme.

Notify the Environment Agency of Compliance within the deadline using the online notification system as soon as the enterprise believes is fully compliant.

Assemble your ESOS Evidential Pack and back it up in a safe place. Remember, it is your responsibility to provide proof of the above. Unearthing evidence a year later it not something to look forward to.

The ESOS assessment process is largely self-regulatory, although there are checks and balances in place including lead assessor and board-level certifications. As you work through what may seem to be a nuisance remember the primary objectives. These are saving money and reducing carbon emissions. Contact ecoVaro if we can assist in any way.

Energy Audit – clearly clear?

An energy audit is an examination of an energy system to ensure that energy is being used efficiently. It is the inspection, survey and analysis of energy flows for energy conservation in a building. Energy audits can be conducted by building managers who examine the energy account of an energy system, checks the way energy is used in its various components, checks for areas of inefficiency or where less energy can be used, and identifies the means for improvement.

An energy audit is often used to identify cost effective ways to improve the comfort and efficiency of buildings. In addition, homes/ enterprises may qualify for energy efficiency grants from central government. Energy audits seek to prioritise the energy uses from the greatest to least cost effective opportunities for energy savings.

An energy audit is an effective energy management tool. By identifying and implementing improvements as identified, savings can be achieved not only on energy bills, but also equipment will be able to attain a longer life under efficient operation. All these mean actual dollar savings.

An energy audit has to be conducted by a competent person with adequate technical knowledge on building services installations, after which he/she comes up with a report recommending plans on the Energy Management Opportunities (EMO) for energy saving.

An energy audit culminates to a written report. This could show energy use for a given time period (for example a year) and the impact of any suggested improvements per year. Energy audit reports are then used to identify cost effective ways to improve the comfort and efficiency of buildings. The energy audit report therefore gives management an understanding of the energy consumption scenario and energy saving plans formulation.
Energy audit reports should always translate into action. No matter how well articulated, the energy management objectives are afterall, an energy audit (EMOs), all the effort will be futile if no action is taken. The link between the audit and action is the audit report. It is therefore important for the audit reports to be understandable for all the target audiences/ readers, all of whom may have diverse needs, hence the reason why they should be clear, concise and comprehensible.

What are the do?s and don’ts when writing energy audit reports?

Avoid technical jargon as much as possible; present information graphically; use different graphics such as pie charts, data tables. Schematics of equipment layouts and digital photos tend to make EMO reports less dry. Some of the energy audit software?s come in handy in the generation of such graphs and charts.
The climax of it all is the recommendations, which should be made very fascinating.

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