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?

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Spreadsheet woes – Burden in SOX Compliance and other Regulations

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2015 – What’s ahead for UK Business?

According to reports just in, the global environment industry is down. Less money is available for what some CEO?s still see as grudge expenditure, and many U.S. agencies are seeking soft budget cuts. The UK is proving to be an exception following the announcement of ESOS, and EcoVaro does not expect the May elections will have much impact in this regard.

ESOS calls for mandatory energy assessments in companies above a certain size, and requires specific proposals to cut consumption. There is no indication of compulsory follow-through, although it is clear the Environment Agency hopes rising electricity prices and the prospect of monetary savings will do the trick.

It is an open question whether the Tory government would have interfered with commerce to this extent, were it not for the European directive that enforced it. The overall goal is to cut EU energy consumption across the board by 20% by 2020. Energy consultants are rubbing their hands in glee. EcoVaro?s response is to provide cloud-based software.

We will be interested to see how many UK companies make the first deadline of 5 December 2015, in the light of reports that half the 9,000 firms affected appear not to even know that ESOS exists. Some will no doubt pay last-minute lip service. Those with an eye on their own sustainability will grasp the Energy Saving Opportunity Scheme with both hands.

The initial ESOS deadline was always going to be a challenge. Some big corporates have stolen a march albeit egged on by green stakeholders. The next challenge comes in June 2015 with the implementation of the European Union?s ?Waste Catalogue? of hazardous substances, and rules for their disposal. We hope a new ISO 14001 will arrive soon and pull the loose threads together.

The introduction of carbon trading late this year brings further opportunities to increase profits through wise stewardship. Auditable metrics are essential for this.

EcoVaro can assist by processing your raw data. We provide this service on a virtual cloud. In return, you can get advice on optimising the quality of your graphs for presentations.

Can you do away with the Project Initiation Meeting?

Project initiation meetings are often skipped to fast-track projects. Once a sponsor is found, organisations go straight to project planning and execution. But based on our own experience, holding a project initiation meeting can actually eliminate many issues that may crop up in the future and hence may speed things up instead in the long run.

It is in the project initiation meeting where your project objectives and scope are clarified and all stakeholders are brought to the same page. Project sponsors and stakeholders will have to know in a nutshell what is needed from them, what the possible risks are, what different resources are required, and so on. So that, when it’s time to proceed to the next phase, everyone is already in-sync.

So what are taken up in such a meeting? Perhaps an actual example can help. Sometime in the past, we set out to work on an eCommerce website project. After conducting the project initiation meeting, these were some of the things we were able to accomplish:

Identified deliverables e.g. site design, interface to payment system, etc.
Come up with the project phases
Agreed what should be in and out of scope
Defined the acceptance test criteria
Identified possible risks
Identified the possible training and documentation work needed
Established whether any analysis was required, e.g. as with regards to payment interfaces
Formulated disaster recovery plans
Defined roles and responsibilities
Drafted timelines and due dates

Aren’t these covered in project planning? If the project is a big one, the answer is no. In a large project, project planning is a much more exhaustive activity. In a project initiation meeting, only the basic framework is defined.

Some questions may still remain unanswered after a project initiation meeting, but at least you already know what answers you need to look for. In the example we gave earlier, we left the meeting knowing that we needed:

a list of all necessary hardware to estimate the costs
to identify possible dependencies we might have with third parties
to identify what software had to be bought and what skills we needed to hire

When it was time to proceed to project planning, everyone involved already knew what direction we were taking. In effect, by not skipping the project initiation meeting, we were able to avoid many potential obstacles.

Key Steps to Complying with ESOS

Energy Savings Opportunity Scheme has already been launched. In fact, it is by now in its initial phase. However, many businesses are still not aware of the new scheme, especially those who are covered by the qualifications for ESOS. To help them understand what they need to do in compliance to the energy efficiency strategy, here are key steps they can follow along the way.

Measure Overall Energy Consumption

The first step to complying with ESOS is to make an initial estimate of the business? energy consumption. This includes measuring the use of electricity, renewable energy, combustible fuels and all other forms of energy consumed whether in buildings, transports and industrial processes.

Three important factors to consider are the measurement units used, the reference period and quality of data. Energy units, such as MWh and GJ, or energy expenditure costs should be applied. Business enterprises should also do the initial measurement within a reference period of 12 months. Moreover, data collected should be verifiable at hand.

Identify Areas of Significant Energy Consumption

When the total energy consumption for all the activities and assets has already been estimated, it’s then time to identify what areas in the organisation comprise the significant portion of the overall energy usage. The areas recognised should cover at least 90% of the overall consumption. Meaning to say, ESOS participants have the chance to omit 10% of the energy consumption and instead focus on the 90%. This would ensure that subsequent energy audits will be cost-effective and proportionate.

Consider and Choose Compliance Routes

In order to comply with ESOS, qualified businesses should consider what compliance routes to take. These routes include taking series of energy audits, operating and implementing a certified ISO 50001 energy management system, acquiring Display Energy Certificates (DECs) and working with Green Deal assessments. Whichever route the business takes, one should maintain credible evidences, along with helpful documents, to certify their compliance.

Report the Compliance

Except when the large enterprise covers all the significant areas of energy consumption by means of ISO 50001 certification, one should appoint a lead assessor to supervise, conduct and review the organisation’s chosen ESOS compliance route. In this case, the approved assessments should then be signed off at board level to ensure that the conclusions and recommendations for energy savings are properly carried. To confirm their compliance, the business should submit a formal notification to the Environment Agency.

Because ESOS is not just an opportunity but also an obligation, it designated compliance bodies and gave them the authority to file civil penalties towards those who fail to comply with the scheme. Not only that, these appropriate authorities have the right to publish information about non-compliant enterprises including their name, details of non-compliance and corresponding penalty amount. Among these UK compliance bodies are Natural Resources Wales, Environment Agency in England, The Scottish Environment Protection Agency (SEPA) and Northern Ireland Environment Agency.

So, if you are covered with the ESOS qualifications, make sure to be informed. As the famous saying goes, ?Ignorance of the law excuses no one.? Likewise, awareness of ESOS is a responsibility every large business in UK should give importance to.

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