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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How Small Irish Businesses Avoid the GDPR Sting

Accountants providing chartered accounting services and tax advice are alerting smaller Irish companies to the consequences of the pending General Data Protection Regulation (GDPR). They believe these are going to feel the most pain come 25 May 2018, if they do not implement GDPR by then. We are trying our best to help avoid this situation by providing advice.

How to Kick the GDPR Ball into Play

The Irish Information Commissioner?s Office has produced a toolkit regarding where?s best to start. They suggest beginning with an information security assessment to determine the gaps companies need to close. Once quantified, this leads naturally to a plan of action, and resources needed to fulfil it. Here?s how to go about it:

1. Start by assessing your current ability to identify, assess, and manage threats to customer data security. Have you done anything at all to date? You must be holding some customer information surely, and it is highly likely the GDPR applies to you.

2. Next, review your company?s current customer data security policies. Are they documented and approved, or do new employees discover them sitting next to Nellie? Rate yourself on a scale where ten is successful implementation.

3. Now consider how well you have pinned responsibilities on individuals to implement policies and take the lead on GDPR. The latter should be the business owner, or a board member with clout to make things happen.

4. By now, you should have a grasp of the scale of work ahead of you, remembering the EU deadline is 25 May 2018. If this sounds overwhelming, consider outsourcing to your accountant or a specialist provider.

5. Under the General Data Protection Regulation you have only 72 hours to report a breach of customer data security to the Information Commissioner?s Office. Do you have a quality assurance mechanism to oversee this?

Tangible Things to Bring Your Own People on Board

With all the changes going on, there is a risk of your employees regarding GDPR as ?another management idea going nowhere.? Thus, it is important to incorporate the new EU regulations in staff training, particularly with regard to data security generally. They may fully come on board only once they see tangible signs of progress. You should in any case put the following measures in place unless you already have them:

1. A secure area for your servers and for any paperwork your customers provided. This implies access control on a need-to-know basis to protect the information against loss, damage, and theft.

2. A protocol for storage media and record disposal when you no longer require them or something supersedes them. You are the custodian of other people?s information and they deserve nothing less.

3. Procedures to secure customer data on employee mobile devices and computers: This must extend to work done at home, at consultant sites, and by remote workers.

4. Secure configuration of all existing and new hardware to minimise vulnerability and storage media crashes. These quality assurance measures should extend to removable media and remote backups.

So Is This the Worst of the Pain?

We are at the heart of the matter, although there is more to tell in future articles. You may be almost there, if you already protect your proprietary information. If not, you may have key company information already open to malware.We should welcome the EU General Data Protection Regulation as a notice that it is time to face up to the challenges of data protection and security generally. The age of hacking and malware is upon us. The offender could be a disgruntled employee, or your competition just down the street. It is time to take precautions.

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2015 ESOS Guidelines Chapter 1 ? Who Qualifies

The base criteria are any UK undertaking that employs more than 250 people and/or has a turnover in excess of ?50 million and/or has a balance sheet total greater than ?43 million. There is little point in attempting to separate off high polluting areas. If one corporate group qualifies for ESOS, then all the others are obligated to take part too. The sterling equivalents of ?38,937,777 and ?33,486,489 were set on 31 December 2014 and apply to the first compliance period.

Representatives of Overseas Entities

UK registered branches of foreign entities are treated as if fully UK owned. They also have to sign up if any overseas corporate element meets the threshold no matter where in the world. The deciding factor is common ownership throughout the ESOS system. ecoVaro appreciates this. We have seen European companies dumping pollution in under-regulated countries for far too long.

Generic Undertakings that Could Comply

The common factor is energy consumption and the organisation’s type of work is irrelevant. The Environmental Agency has provided the following generic checklist of undertakings that could qualify:

Limited Companies	Public Companies	Trusts
Partnerships	Private Equity Companies	Limited Liability Partnerships
Unincorporated Associations	Not-for-Profit Bodies	Universities (Per Funding)

Organisations Close to Thresholds

Organisations that come close to, but do not quite meet the qualification threshold should cast their minds back to previous accounting periods, because ESOS considers current and previous years. The exact wording in the regulations states:

?Where, in any accounting period, an undertaking is a large undertaking (or a small or medium undertaking, as the case may be), it retains that status until it falls within the definition of a small or medium undertaking (or a large undertaking, as the case may be) for two consecutive accounting periods.?

Considering the ?50,000 penalty for not completing an assessment or making a false or misleading statement, it makes good sense for close misses to comply.

Joint Ventures and Participative Undertakings

If one element of a UK group qualifies for ESOS, then the others must follow suit with the highest one carrying responsibility. Franchisees are independent undertakings although they may collectively agree to participate. If trusts receive energy from a third party that must do an ESOS, then so must they. Private equity firms and private finance initiatives receive the same treatment as other enterprises. De-aggregations must be in writing following which separated ESOS accountability applies.

Spreadsheet Woes – Limited Features For Easy Adoption of a Control Framework

Like it or not, regulations are here to stay and for a company to comply with them, its IT and financial systems will have to be equipped with a suitable control framework. One common stumbling block to such an implementation is a company?s over-reliance on spreadsheets. (more…)