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

 

Spreadsheet Risks in Banks

 

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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How Bombardier Inc. scored a Bulls Eye

When travelling anywhere in the world on land, sea or air, chances are, you will travel courtesy of something made by aerospace and transportation company Bombardier based in Montreal, Canada. In 2009, it set itself the goal of carbon neutrality by 2020. In other words, it hoped to remove as much carbon dioxide from the atmosphere as it was putting in.

By 2012, Bombardier concluded it was not going to become carbon neutral by 2020 at its current rate of progress. It discounted purchasing carbon offsets because it believed it would serve its interests better by introducing new energy-saving products to market faster. That way, it would achieve its objectives vicariously through the decisions of its customers. But that was not all that forward-thinking Bombardier did. It also set itself the following inward-facing objectives:

  • Reduce carbon footprint through efficient use of energy and less emissions
  • Involve the Bombardier workforce to raise awareness of behaving responsibly
  • Implement sustainable initiatives to further reduce the company carbon footprint

Specific Examples

At its Wichita site, Bombardier (a) fitted a white roof and insulation reducing summer energy consumption by 40%, (b) added an energy recovery wheel to balance air circulation, and (c) introduced skylights with integrated controllers to lower energy consumption by lighting.

At Mirabel, it enhanced the flue-gas management system by adding a pressure differential damper.

At Belfast, Bombardier (a) optimised HVAC systems to reduce pressure on chilling and air-handling plants, (b) installed solar panels on the roof, and (c) obtained approval for a waste-to-energy plant that will convert 120,000 tonnes of non-recyclable waste material annually.

By the end of 2013, Bombardier had already beaten its immediate targets by:

  • Reducing energy consumption by 11% against 2009
  • Reducing greenhouse gas emission by 23% against 2009
  • Reducing water consumption by 6% against 2012

Future Plans

Bombardier will never stop striving to reach its goal of carbon neutrality by 2020. It has a number of other projects in the pipeline waiting for scarce resources to fund them. During 2014, it continued with energy efficient upgrades at its French, Hungarian, Polish, Swiss, and UK plants.

These include consumption monitoring systems, LEDs for workshop lighting, new heating systems, and outdoor energy-saving tower lighting. The monitoring is important because it helps Bombardier focus effort, and provides measured proof of progress.

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2015 ESOS Guidelines Chapter 7, 8 & 9 – Sign-Off, Compliance & Appeals

This is the final chapter in our series of short posts summarising the quite complex ESOS guidelines (click on ?Comply with ESOS? to see the details). This one addresses the legalities to follow to complete your report – and how to appeal if you are not happy with any of the Environment Agency?s decisions.

  1. Director Sign-Off

This is by no means an easy ride. Confirmation of the work at individual or lead assessor level locks the company into the penalty cycle in the event there are significant irregularities. By signing off the assessment, the board level director(s) # agree that they have

  • Reviewed the enterprise?s ESOS recommendations
  • Believe the enterprise is within the scope of the scheme
  • Believe the enterprise is compliant with the scheme
  • Believe the information provided is correct

Having an internal assessor requires a second board-level signature.

  1. Compliance

You report compliance on the internet. This is free and you can do it at any time within the deadline. You can dip in and out of the process as many times as you wish, but must use the link in the receipting email. While this is something a board member must do, there is no reason why the lead assessor should not complete the basics. The online compliance notification addresses the following topics:

  • The ESOS contact person in the enterprise
  • Any aggregation / dis-aggregation during the period
  • The names and contact details of the lead assessor
  • The proportion of energy consumption per compliance route

The Environment Agency will acknowledge receipt. This does not constitute acceptance. You should keep the ESOS evidence pack in a safe place with at least one backup elsewhere.

  1. Compliance & Enforcement Issues

In the event the Environment Agency decides your enterprise has not met ESOS requirements, it may either (a) issue a compliance notice with instructions, or (b) apply one of the following civil penalties:

  • A fine of up to ?5,000 for failure to maintain records
  • A fine of up to ?50,000 for failure to undertake an energy audit
  • A fine of up to ?50,000 for a false or misleading statement

Any enterprise has the right of appeal against government decisions. In the case of ESOS, this is via:

  • The First-Tier Tribunal if your enterprise is England, Wales or off-shore based
  • The Scottish Minister if your enterprise is based in Scotland
  • The Planning Commission if your enterprise is Northern Ireland-based

The notice you appeal against will supply details of the appeal steps to take.

This blog and its companion chapters concerning the ESOS Guidelines as amended 2015 are with compliments of ecoVaro. We are the people who break ESOS data into manageable chunks of information, so that board-level directors have greater confidence in what they sign.

How Sustainable is Suez Environment

French-based Suez Environment works in the water and waste-management environment, with specific reference to water production, treatment, & pollution disposal, and waste treatment, recycling, incineration and site desensitisation. Its more than 65,000 employees distributed worldwide have participated in flagship projects like Renault’s goal of 95% reclamation of vehicle parts, and Lyonnaise des Eaux?s saving of 12 million cubic meters of water in a single year.

Suez Environment claims to have consistently increased the recovery rate of treated waste, decreased direct and indirect greenhouse gas emissions, and made significant inroads into the production of sustainable energy on behalf of its clients. But then surely that’s Suez Environment’s business, and with over 65,000 employees we are entitled to expect this. Given that there have been persistent allegations of privatised water distribution bumping prices up to the detriment of the poor, how effective is Suez Environment at practising what it preaches back home?

GDF Suez is its largest shareholder and includes it under its environmental and societal responsibility umbrella. This makes environmental performance an overarching goal alongside management systems, health and safety, risk and procurement, and ethics. Its environmental ambitions spin out into the following strategies:

  • Understand the interactions between our activities and the environment
  • Open dialogue with stakeholders and foster partnerships with them
  • Set quantitative and qualitative targets at all levels of the organisation
  • Achieve optimum balance between financial and environmental challenges
  • Be proactive; anticipate impacts on the environment and plan for them
  • Increase employee awareness through interactive training and education
  • Be constantly innovative; share successes within the organisation
  • Monitor progress continuously and publish measured results achieved.

These goals direct the Suez Environment management team?s attention towards optimising performance in key areas like greenhouse gases, energy management, renewable energy, biodiversity, responsible water management, pollution prevention and health and safety considerations.

Among numerous other examples, its waste incineration programs convert hazardous and conventional waste into heat used to generate electricity without requiring virgin carbon products. Elsewhere, the same energy warms market-gardening tunnels and work places on winter days.

Suez Environment uses sophisticated energy management software to analyse information that’s transmitted by data logging devices online. ecoVaro provides a similar service in the cloud. ecoVaro adapts to your requirements providing fresh insights to your business.

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