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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2015 ESOS Guidelines Chapter 2 – Deadlines and Status Changes

The ESOS process is deadline driven and meeting key dates is a non-negotiable. The penalties for not complying / providing false or misleading information are ?50,000 each. Simply not maintaining adequate records could cost you ?5,000. The carrot on the end of the stick is the financial benefits you stand to gain.

Qualifying for inclusion under the ESOS umbrella depends on the status of your company in terms of employee numbers, turnover and balance sheet on 31 December 2014. Regardless of whether you meet the 2014 threshold or not, you must reconsider your situation on 31 December 2018, 2022 and 2026.

Compliance Period Qualification Date Compliance Period Compliance Date
1 31 December 2014 From 17 July 2014* to 5 December 2015 5 December 2015
2 31 December 2018 From 6 December 2015 to 5 December 2019 5 December 2019
3 31 December 2022 From 6 December 2019 to 5 December 2023 5 December 2023
4 31 December 2026 From 6 December 2023 to 5 December 2027 5 December 2027

Notes:

1. The first compliance period begins on the date the regulations became effective

2. Energy audits from 6 December 2011 onward may go towards the first compliance report

Changes in Organisation Status

If your organisation status changes after a qualification date when you met compliance thresholds, you are still bound to complete your ESOS assessment for that compliance period. This is regardless of any change in size or structure. Your qualification status then remains in force until the next qualification date when you must reconsider it.

Competencies, Roles and Responsibilities of Lead Assessors

Any organisation that opts for energy audits, Display of Energy Certificates and Green Deal Assessments needs a lead assessor to review the chosen ESOS compliance routes. The Derivative provides that energy audits should be carried out independently by qualified and accredited experts. Additionally, these audits should be implemented as well as supervised by independent authorities under the national legislation.

Lead assessors undertake several roles in ESOS assessments. He or she is the one responsible to take the lead of the entire assessment team, prepare the plan, conduct the meetings and submit the formal report to governing authorities. Nevertheless, selecting an appropriate lead assessor is an important element that every organisation should carefully consider.

Competencies Requirements of Lead Assessors

Lead assessors should be knowledgeable enough with in-depth expertise in carrying out energy efficiency assessment. They should also possess foundational, functional and technical competencies to deliver the task effectively. Likewise, consider the assessors? sector experiences, familiarity with your business? technologies and properties, and accreditation with prescribed standards.

As you choose your lead assessor, contemplate on the skills and qualifications that would give your organisation benefits.

Roles and Responsibilities of Lead Assessors

The business organisation is responsible for the overall legal ESOS compliance. Moreover, here are some of the roles and responsibilities that lead assessors should assume in ESOS assessments.

The lead assessor agrees on the audit methodologies that the organisation would undergo in new audits. He or she agrees with the ESOS participant regarding the audit timetable, sampling approach and visits required. It is also the lead assessor?s role to identify the opportunities on energy saving and assist in calculating the cost savings from the measures taken. During the ESOS audits, the lead assessor determines the energy use profiles, presents the recommendations and reviews the entire assessment as a whole. Furthermore, he or she should maintain the evidence pack of the ESOS to uphold the audit’s credibility, its findings and recommendations.

Finding Lead Assessors

Energy and environment professionals would only be able to demonstrate their expertise as lead assessors upon registering in a professional body accredited by the Environment Agency. Any business that needs a lead assessor is advised to check on the EA?s website to see the details of approved registers.

Lead assessors can either be in-house experts or external professionals. However, they should be able to provide proof of membership as an approved register to take the role of a lead assessor. If the organisation has an internal lead assessor, the company should then take the final ESOS assessment to two board-level directors that would sign the formal report.

Indeed, the lead assessor is an organisation’s partner when it comes to delivering great results. With good professional conduct and excellent management of an assessment team, the lead assessor can help achieve breakthrough energy efficiency strategies. More than anything else, the organisation will benefit from maximum energy savings opportunities ahead. Thus, every qualified business enterprise should invest in finding the best lead assessor to guide them towards success.

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What Energy Management Software did for CDC

Chrome Deposit Corporation ? that’s CDC for short ? reconditions giant rollers used to finish steel and aluminium sheets in Portage, Indiana by applying grinding, texturing and plating methods. While management was initially surprised when the University of Delaware singled their plant out for energy assessment, this took them on a journey to bring energy consumption down despite being in an expansion phase.

Metal finishing and refinishing is an energy-intensive business where machines mainly do the work while workforces as small as 50 individuals tend them. Environmental impacts also need countering within a challenging environment of burgeoning natural gas and electricity prices.

The Consultant’s Recommendations

The University of Delaware was fortunate that Chrome Deposit Corporation had consistently measured its energy consumption since inception in 1986. This enabled it to pinpoint six strategies as having potential for technological and process improvements.

  • Insulate condensate tanks and pipes
  • Analyse flue gas air-fuel ratios
  • Lower compressed air pressures
  • Install stack dampers on boilers
  • Replace belts with pulleys and cogs
  • Fit covers on plant exhaust fans

CDC implemented only four of the six recommendations. This was because the boiler manufacturer did not recommend stack dampers, and the company was unable to afford certain process automation and controls.

Natural Gas Savings

The project team began by analysing stack gases from boilers used to heat chrome tanks and evaporate wastewater. They found the boilers were burning rich and that several joints in gas lines were leaking. Correcting these issues achieved an instant gas saving of 12% despite increased production.

Reduced Water Consumption

The team established that city water was used to cool the rectifiers. It reduced this by an astonishing 85% by implementing a closed-loop system and adding two chillers. This also helped the water company spend less on chemicals, and energy to drive pumps, purifiers and fans.

Summary of Benefits

Electricity consumption reduced by 18% in real terms, and natural gas by 35%. When these two savings are merged they represent an overall 25% energy saving. These benefits were implemented across the company?s six other plants, resulting in benefits CDC management never dreamed of when the University of Delaware approached them.

ecoVaro offers a similar data analytics service that is available online worldwide. We have helped other companies slash their energy bills with similarly exciting results. We?ll be delighted to share ideas that only data analytics can reveal.

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