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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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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Becoming Nimble the Agile Project Management Way

In dictionary terms, ?agile? means ?able to move quickly and easily?. In project management terms, the definition is ?project management characterized by division of tasks into short work phases called ?sprints?, with frequent reassessments and adaptation of plans?. This technique is popular in software development but is also useful when rolling out other projects.

Managing the Seven Agile Development Phases

Stage 1: Vision. Define the software product in terms of how it will support the company vision and strategy, and what value it will provide the user. Customer satisfaction is of paramount value including accommodating user requirement changes.
Stage 2: Product Roadmap. Appoint a product owner responsible for liaising with the customer, business stakeholders and the development team. Task the owner with writing a high-level product description, creating a loose time frame and estimating effort for each phase.
Stage 3: Release Plan. Agile always looks ahead towards the benefits that will flow. Once agreed, the Product Road-map becomes the target deadline for delivery. With Vision, Road Map and Release Plan in place the next stage is to divide the project into manageable chunks, which may be parallel or serial.
Stage 4: Sprint Plans. Manage each of these phases as individual ?sprints?, with emphasis on speed and meeting targets. Before the development team starts working, make sure it agrees a common goal, identifies requirements and lists the tasks it will perform.
Stage 5: Daily Meetings. Meet with the development team each morning for a 15-minute review. Discuss what happened yesterday, identify and celebrate progress, and find a way to resolve or work around roadblocks. The goal is to get to alpha phase quickly. Nice-to-haves can be part of subsequent upgrades.
Stage 6: Sprint Review. When the phase of the project is complete, facilitate a sprint review with the team to confirm this. Invite the customer, business stakeholders and development team to a presentation where you demonstrate the project/ project phase that is implemented.
Stage 7: Sprint Retrospective. Call the team together again (the next day if possible) for a project review to discuss lessons learned. Focus on achievements and how to do even better next time. Document and implement process changes.

The Seven Agile Development Phases ? Conclusions and Thoughts

The Agile method is an excellent way of motivating project teams, achieving goals and building result-based communities. It is however, not a static system. The product owner must conduct regular, separate reviews with the customer too.

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 3 ? The ESOS Assessment

ESOS operates in tandem with the ISO 50001 (Energy Management) system that encourages continual improvement in the efficient use of energy. Any UK enterprise qualifying for ESOS that has current ISO 50001 certification on the compliance date by an approved body (and that covers the entire UK corporate group) may present this as evidence of having completed its ESOS assessment. It does however still require board-level certification, following which it must notify the Environment Agency accordingly.

The Alternate ESOS Route

In the absence of an ISO 50001 energy management certificate addressing comprehensive energy use, a qualifying UK enterprise must:

Measure Total Energy Consumption in either kWh or energy spend in pounds sterling, and across the entire operation including buildings, industrial processes and transport.
Identify Areas of Significant Energy Consumption that account for at least 90% of the total. The balance falls into a de minimis group that is officially too trivial to merit consideration.
Consider Available Routes to Compliance. These could include ISO 500001 part-certification, display energy certificates, green deal assessments, ESOS compliant energy audits, self-audits and independent assessments
Do an Internal Review to make sure that you have covered every area of significant consumption. This is an important strategic step to avoid the possibility of failing to comply completely.
Appoint an Approved Lead Assessor who may be internal or external to your enterprise, but must have ESOS approval. This person confirms you have met all ESOS requirements (unless you have no de minimis exceptions).
Obtain Internal Certification by one of more board-level directors. They must certify they are satisfied with the veracity of the reports. They must also confirm that the enterprise is compliant with the scheme.
Notify the Environment Agency of Compliance within the deadline using the online notification system at snapsurveys.com as soon as the enterprise believes is fully compliant.
Assemble your ESOS Evidential Pack and back it up in a safe place. Remember, it is your responsibility to provide proof of the above. Unearthing evidence a year later it not something to look forward to.

The ESOS assessment process is largely self-regulatory, although there are checks and balances in place including lead assessor and board-level certifications. As you work through what may seem to be a nuisance remember the primary objectives. These are saving money and reducing carbon emissions. Contact Ecovaro if we can assist in any way.