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

 

Spreadsheet Risks in Banks

 

Top 10 Disadvantages of Spreadsheets

 

Disadvantages of Spreadsheets – obstacles to compliance in the Healthcare Industry

 

How Internal Auditors can win the War against Spreadsheet Fraud

 

Spreadsheet Reporting – No Room in your company in an age of Business Intelligence

 

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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UK Hauliers Pull Together on ESOS

ESOS is what UK business needed, to encourage it to become more responsible for the environmental consequences of making money. Government has met with industry leaders to hammer out the finer details. Now there are heartening signs of intra-industry collaboration, for the example the FTA approach we discuss here.

The Freight Transport Association (FTA) is one of the UK?s biggest trade associations, and exists to represent the interests of companies moving goods by air, rail, sea and road. It is their representative at national, European and local level that advises them on legal compliance. In February 2015, it announced plans to help the industry comply with ESOS too.

The association has been active since the announcement of the UK?s Energy Saving Opportunity Scheme. It has engaged with government and membership through the portal of its Logistics Carbon Reduction Scheme (LCRS). The Environment Agency has singled this out as a benchmark other industries could follow.

FTA general manager for consultancy and tendering Karen Packham recently said, ?With our highly experienced and fully qualified team of transport auditors ?the FTA is best placed to offer practical advice and is able to provide specialist audits to ensure members are fully compliant ? and will gain all the benefits that the scheme has to offer.?

These co-audits with Environment Agency specialists advising, will focus on the full range of operational and supporting activities, and ensure that all haulage companies with over 250 employees do the following:

  • Assess energy use across their full spread of buildings, transport media and industrial activity
  • Examine energy-intensive pressure points and identify savings opportunities that provide financial benefit
  • Nominate an ESOS person to conduct future audits, or oversee and approve them independently
  • Report to the Environment Agency as scheme administrator per statutory intervals

Ecovaro has energy management software that turns metrics into high-level information that busy people understand. Give us a call if you are puzzling how best to present your data. We believe two heads can achieve so much more together.

How Westin Melbourne Hotel Trimmed its Footprint

Becoming sustainable is a three-pronged process. You must save money and push the buttons the government is pressing you to. But there?s a deeper, more urgent issue. If your customers mark you down for not being green enough you are heading for trouble. Let’s see how well this hotel is doing.

The Melbourne flagship of the Westin hotel chain boasts 262 spacious rooms with views of Melbourne Square and surrounding theatres, designer boutiques, galleries and national landmarks. The architects included conference facilities, a wellness centre and sundry bars and restaurants. After climate change arrived to stay, hotel management discovered they had inherited a water and energy-greedy monster. Their solution was to measure what was going through their systems, and then progressively cap the building?s greedy appetite.

The Melbourne Westin Hotel could not have achieved results without these metrics. They began by determining key indicators and measuring them. This provided them with criteria to set achievable, cost effective targets in the following key areas of their business:

  1. Water Management ? Demand-based linen and towel recycling, installation of back-washable water filters, water-saving shower heads, dual-flush toilets.
  2. Waste Management ? Conversion to green products, recycling kitchen oil, moving towards a paperless office, recycling everything possible.
  3. Energy Management ? Energy-efficient light bulbs, standby settings for lights, computers, televisions and air conditioners
  4. Stakeholder Communication ? Staff green-team training, guest education, ongoing employee briefings
  5. Strategic Positioning ? Visible, top-down commitment, optimised carbon offsets from clean, renewable energy sources, clearly stated position in the market

Westin?s Melbourne landmark has made good progress towards becoming the green hotel for others to follow. It has adjusted its environmental policies, increased water and energy awareness and implemented tight waste management.

Consumers are already shopping to make their carbon footsteps lighter. Food stores are on the bandwagon although apparel is lagging. Perhaps it’s time you found out just how your company is shaping up. It’s no longer a matter of ?if carbon taxes?. It’s a matter of ?when it does?.

ecoVaro is a software system-in-the-cloud that lets you enter your water and energy consumption and process it online so you can monitor and manage your usage. In no time at all you could be saving money like Westin Melbourne did. Does that sound like something worth investigating?

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2015 ESOS Guidelines Chapter 7, 8 & 9 – Sign-Off, Compliance & Appeals

This is the final chapter in our series of short posts summarising the quite complex ESOS guidelines (click on ?Comply with ESOS? to see the details). This one addresses the legalities to follow to complete your report – and how to appeal if you are not happy with any of the Environment Agency?s decisions.

  1. Director Sign-Off

This is by no means an easy ride. Confirmation of the work at individual or lead assessor level locks the company into the penalty cycle in the event there are significant irregularities. By signing off the assessment, the board level director(s) # agree that they have

  • Reviewed the enterprise?s ESOS recommendations
  • Believe the enterprise is within the scope of the scheme
  • Believe the enterprise is compliant with the scheme
  • Believe the information provided is correct

Having an internal assessor requires a second board-level signature.

  1. Compliance

You report compliance on the internet. This is free and you can do it at any time within the deadline. You can dip in and out of the process as many times as you wish, but must use the link in the receipting email. While this is something a board member must do, there is no reason why the lead assessor should not complete the basics. The online compliance notification addresses the following topics:

  • The ESOS contact person in the enterprise
  • Any aggregation / dis-aggregation during the period
  • The names and contact details of the lead assessor
  • The proportion of energy consumption per compliance route

The Environment Agency will acknowledge receipt. This does not constitute acceptance. You should keep the ESOS evidence pack in a safe place with at least one backup elsewhere.

  1. Compliance & Enforcement Issues

In the event the Environment Agency decides your enterprise has not met ESOS requirements, it may either (a) issue a compliance notice with instructions, or (b) apply one of the following civil penalties:

  • A fine of up to ?5,000 for failure to maintain records
  • A fine of up to ?50,000 for failure to undertake an energy audit
  • A fine of up to ?50,000 for a false or misleading statement

Any enterprise has the right of appeal against government decisions. In the case of ESOS, this is via:

  • The First-Tier Tribunal if your enterprise is England, Wales or off-shore based
  • The Scottish Minister if your enterprise is based in Scotland
  • The Planning Commission if your enterprise is Northern Ireland-based

The notice you appeal against will supply details of the appeal steps to take.

This blog and its companion chapters concerning the ESOS Guidelines as amended 2015 are with compliments of ecoVaro. We are the people who break ESOS data into manageable chunks of information, so that board-level directors have greater confidence in what they sign.

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