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 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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Is the GDPR Good or Bad News for Business

The European Union?s General Data Protection Act (GDPR) is a new data authority coming into force on 25 May 2018. It replaces the current Data Protection Directive 95/46/EC, while extending the remit to include the export of personal data outside the EU. It aims to give EU citizens and residents living there more control over their personal information. It also hopes to make regulatory compliance simpler for participating businesses.

The Broad Implications for Business
The GDPR puts another layer of accountability on businesses falling within its remit. It requires them to implement ?comprehensive but proportionate governance measures? including recording how they make decisions. The long-term goal is to reduce privacy infringements. In the short run, businesses without good governance may find themselves writing new policies and procedures.

Article 5 of the European Union?s General Data Protection Act lays down the following guidelines for managing personal data. This shall be ?
? Processed transparently, fairly, and lawfully
? Acquired for specific, legitimate purposes only
? Adequate, relevant and limited to essentials
? Not used for any other, incompatible purpose
? However it may be archived in the public interest
? Kept up to date with all inaccuracies corrected
? Ring-fenced when the information becomes irrelevant
? Adequately protected against unauthorised access
? Stored in a way that prevents accidental loss
Furthermore, affected businesses shall appoint a ?controller responsible for, and able to demonstrate, compliance with the principles.?

Implementing Accountability and Governance
The UK Information Commissioner?s Office has issued guidelines regarding provisions to assure governance and accountability. These are along the lines of the ?don’t tell me, show me? management approach the office has generally been following. In summary form, a business, and its controller must:
? Implement measures that assist it to ensure demonstrated compliance
? Maintain suitable, relevant records of personal data processing activities
? Appoint a dedicated data protection officer if scale makes this appropriate
? Implement technologies that ensure data protection by design
? Conduct data protection assessments and respond to results timeously

Implementing the General Data Protection Act in Ireland
The Irish Data Protection Commissioner has decided it is unnecessary to incorporate the GDPR into Irish law, since EU regulations have direct effect. The office of the Commissioner is working in tandem with data practitioners, and industry and professional bodies to raise awareness in business through 2017. It has produced a document detailing what it considers the essentials for business compliance. Briefly, these pre-requisites are:
? Ensure awareness among key personnel, and make sure they incorporate the GDPR into their planning
? Conduct an early assessment of quality management gaps, and budget for additional resources needed
? Do an audit of personal data held, to determine the origin, the necessity to hold it, and with whom shared
? Inform internal and external stakeholders of the current status, and your future plans to implement the GDPR
? Examine current procedures in the light of the new directive. Could you ?survive? a challenge from a data subject?
? Determine how you will process requests for access to the data in the future from within and outside your organization
? Assess how you currently obtain customer consent to store their data. Is this “freely given, specific, informed and unambiguous”?
? Find how you handle information from underage people. Do you have systems to verify ages and obtain guardian consent?
? Implement procedures to detect, investigate, and report data breaches to the Data Protection Commissioner within 72 hours
? Implement a culture of always assessing the effect on individual privacy before starting new initiatives

So Is the GDPR Good or Bad for Business
The GDPR should be good news for business customers. Their personal data will be more secure, and they should see their rate of spam marketing come down. The GDPR is also good news for businesses currently investing resources to protect their clients? interests. It could however, be bad news for businesses that have not been focussing on these matters. They may have a high mountain to climb to come in line with the GDPR.
Disclaimer: This article is for information only and not intended as a comprehensive guide.

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2015 ESOS Guidelines Chapter 6 – Role of Lead Assessor

The primary role of the lead assessor is to make sure the enterprise?s assessment meets ESOS requirements. Their contribution is mandatory, with the only exception being where 100% of energy consumption received attention in an ISO 50001 that forms the basis of the ESOS report.

How to Find a Lead Assessor

An enterprise subject to ESOS must negotiate with a lead assessor with the necessary specialisms from one of the panels approved by the UK government. This can be a person within the organisation or an third party. If independent, then only one director of the enterprise need countersign the assessment report. If an employee, then two signatures are necessary. Before reaching a decision, consider

Whether the person has auditing experience in the sector
Whether they are familiar with the technology and the processes
Whether they have experience of auditing against a standard

The choice rests on the enterprise itself. The lead assessor performs the appointed role.

The Lead Assessor?s Role

The Lead Assessor?s main job is reviewing an ESOS assessment prepared by others against the standard, and deciding whether it meets the requirements. They may also contribute towards it. Typically their role includes:

Checking the calculation for total energy consumption across the entire enterprise
Reviewing the process whereby the 90% areas of significant consumption were identified
Confirming that certifications are in place for all alternate routes to compliance chosen
Checking that the audit reports meet the minimum criteria laid down by the ESOS system

Note: A lead assessor may partly prepare the assessment themselves, or simply verify that others did it correctly.

In the former instance a lead assessor might

Determine energy use profiles
Identify savings opportunities
Calculate savings measures
Present audit findings
Determine future methodology
Define sampling methods
Develop audit timetables
Establish site visit programs
Assemble ESOS information pack

Core Enterprise Responsibilities

The enterprise cannot absolve itself from responsibility for good governance. Accordingly, it remains liable for

Ensuring compliance with ESOS requirements
Selecting and appointing the lead assessor
Drawing attention to previous audit work
Agreeing with what the lead assessor does
Requesting directors to sign the assessment

The Environment Agency does not provide assessment templates as it believes this reduces the administrative burden on the enterprises it serves.

Web Analytics

There’s a vast ocean of raw customer data on the Web. Ever thought of the implications if somehow you could harness all that data and transform it into useful information? Information that perhaps you can use in your SEO (Search Engine Optimisation) and conversion optimisation?

There are web analytics tools you can employ for these purposes. But using web analytics tools will only win you half the battle. You’ll have to be proficient in configuring these tools to generate insightful and actionable results out of them. A poorly configured tool can produce confusing or even misleading information.

Our web analysts possess the expertise to configure and use web analytics tools, as well as analyse results and leverage information obtained from them.

These are the things we can do to help you take advantage of web analytics.

Discuss with your managers to establish your specific goals, to determine what specific data we have to collect/analyse and to plan out how to go about with the entire process.
Help you select an appropriate tool, install it and set optimal configurations including page tags, filters, funnels, reports and others.
Wield the full force of your analytics tool(s) to make sound business decisions.
Monitor the entire web analytics system and implement adjustments when needed.