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

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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

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Monitoring Water Banks with Telemetrics

Longstanding droughts across South Australia are forcing farmers to rethink the moisture in the soil they once regarded as their inalienable right. Trend monitoring is an essential input to applying pesticides and fertilisers in balanced ratios. Soil moisture sensors are transmitting data to central points for onward processing on a cloud, and this is making a positive difference to agricultural output.

Peter Buss, co-founder of Sentek Technology calls ground moisture a water bank and manufactures ground sensors to interrogate it. His hometown of Adelaide is in one of the driest states in Australia. This makes monitoring soil water even more critical, if agriculture is to continue. Sentek has been helping farmers deliver optimum amounts of water since 1992.

The analogy of a water bank is interesting. Agriculturists must ?bank? water for less-than-rainy days instead of squeezing the last drop. They need a stream of online data and a safe place somewhere in the cloud to curate it. Sentek is in the lead in places as remote as Peru?s Atacamba desert and the mountains of Mongolia, where it supports sustainable floriculture, forestry, horticulture, pastures, row crops and viticulture through precise delivery of scarce water.

This relies on precision measurement using a variety of drill and drop probes with sensors fixed at 4? / 10cm increments along multiples of 12? / 30cm up to 4 times. These probe soil moisture, soil temperature and soil salinity, and are readily re-positioned to other locations as crops rotate.

Peter Buss is convinced that measurement is a means to the end and only the beginning. ?Too often, growers start watering when plants don’t really need it, wasting water, energy, and labour. By monitoring that need accurately, that water can be saved until later when the plant really needs it.? He goes on to add that the crop is the ultimate sensor, and that ?we should ask the plant what it needs?.

This takes the debate a stage further. Water wise farmers should plant water-wise crops, not try to close the stable door after the horse has bolted and dry years return. The South Australia government thinks the answer also lies in correct farm dam management. It wants farmers to build ones that allow sufficient water to bypass in order to sustain the natural environment too.

There is more to water management than squeezing the last drop. Soil moisture goes beyond measuring for profit. It is about farming sustainably using data from sensors to guide us. ecoVaro is ahead of the curve as we explore imaginative ways to exploit the data these provide for the common good of all.

ESOS Facts on a Page

The UK?s ESOS energy saving program stands for ?Energy Savings Opportunity Scheme?. Its purpose is to reduce demand – and hence fossil-based pollution at both ends of the supply chain. It currently applies to large UK companies only. However its guidelines are also valuable input to smaller firms voluntarily going greener.

The program threshold is 250 employees and / or turnover or at least ?UK50 million. This affects approximately 9,000 UK firms, with others below the threshold wondering whether the government plans to lower it. In essence, ESOS requires that qualifying businesses complete comprehensive audits of energy use and opportunities at least every fourth year.

The plan is carrot and stick. Compliant companies will probably uncover significant savings when they stop and measure. They may even unearth carbon credits they can sometime exchange for cash. Reactionary firms who try to duck the issue will feel Her Majesty?s wrath through stiff penalties. In time, they may find it harder to attract investors. If ESOS affects your company, then the wise thing could be complying by the first deadline of 5 December 2015.

To do so, you must conduct an energy audit and report it to the UK Environment Agency. This comprises

Measuring total energy use across processes, transport and facilities
Pie charting 90% of this to identify areas that are energy intensive
Singling out cost-effective energy-saving projects in high use areas
Submitting your report to the Environment Agency ahead of the deadline

ecoVaro recommends affected companies do not leave this to the last minute. While having ISO 50001 may exempt some from ESOS, the regulations are far from straightforward and it will take months to reach complete clarification. We would like to suggest a more balanced approach.

ESOS is a wonderful incentive to save energy costs while contributing to a better future for the kids. The Energy Savings Opportunity Scheme is precisely that. The cost of energy has crept up on us to the extent that we have to do something, government or no government.

Measuring energy consumption is as simple as installing meters at critical points in the flow, and you probably have many of them anyway. Once you have your data you no longer have to crunch the numbers. ecoVaro can do this for you and return the result in the form of handy graphs and spreadsheets.

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.