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.

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Disadvantages of Spreadsheets – obstacles to compliance in the Healthcare Industry

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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.

What ISO 14001 Status did for Cummins Inc.

Cummins manufactures engines and power generation products, and has been a household name almost since inception in 1919. It sells its products in over 300 countries, through approximately 6,000 dealerships employing 40,000 people. Because its product line runs off fossil fuel it is under steady pressure to display a cleaner carbon footprint.

Cummins decided to go for the big one by qualifying for ISO 14001 certification. This is a subset of a family of standards relating to managing environmental impact while complying with all applicable legislation. In this sense, it is similar to the ISO 9000 quality management system, because it focuses on how products are produced (as opposed to how those products perform). Compliance with ISO 14001 was a doubly important goal, because it is part of the European Union?s Eco Management and Audit Scheme and fast becoming mandatory on suppliers to governments.

The qualification process follows the well-established principle of plan, do, check, act. It begins with gap analysis to detect materials and processes that affect the environment. This is followed by implementation of necessary changes affecting operations, documentation, emergency strategies and employee education. The third step involves measuring and monitoring performance. Finally, the project moves into a phase of ongoing maintenance, and continuous improvement as circumstances change.

In Cummins case, the project was almost worldwide and called for environmental, health and safety reporting throughout the organisation. The information was shared via a globally accessible document repository, and then processed centrally at the head office in Columbia, Indiana USA.

Measuring environmental performance almost inevitably has other benefits that make it doubly worthwhile. Speaking at the 2014 National Safety Council Congress after receiving the top award for excellence, Cummins chairman and ceo Tom Linebarger commented on a journey that was ?nothing short of amazing? yet wasn’t even a ?pathway to the finish line?.

?All of us feel like we have way more to do to make sure that our environment is as safe as it could be,? he added, ?so that our sustainability footprint is as good as it can be and that we continue to set more aggressive goals every year. That’s just how we think about it.? Linebarger concluded.

If you are taking your company on a journey to new heights of environmental excellence, then you should consider choosing ecoVaro as your travelling companion. We are environmental management specialists and have proprietary software geared to process your data. We also have a wealth of experience, and a treasure chest of roadmaps to help you achieve your goal.

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.