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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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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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.

What GDPR Means in Practice for Irish Business

The General Data Protection Regulation (GDPR) is a European directive aimed at ring-fencing consumer data against illegal or unnecessary access. There is nothing to discuss or debate with local politicians, or the Irish Data Protection Commissioner for that matter. As a European directive, it has over-riding power. To obtain an English version, please visit this link, and select ?EN? from the table of languages.

As you reach for your tea, coffee or Guinness after sighting it, you will be glad to know the Irish Data Protection Commissioner has the lead in turning this into business English we understand. The following diagram should assist you to obtain a quick overview of the process we all have to go through. In this article, we briefly describe what is inside Boxes 1 to 12. The regulation comes into force on 25 May 2018 so we have less than a year to get ready.

The 12 Essential Steps to Implementing the General Data Protection Act

1. Create awareness among your people of what is coming their way. The GDPR has given our regulator discretion to dish out fines up to ?20,000,000 (or 4% of total annual global turnover, whichever is greater) so there is determination to make this happen.

2. Become accountable by understanding the consumer data you hold. Why are you retaining it, how did you obtain it, and why did you originally collect it. Now you know it is there, how much longer will you still need it? How secure is it in your hands, have you ever shared it?

3. Open a communication channel with your staff, your customers, and anyone else using the data. Share how you feel about how accountable you have been with the information in the past. Explain how you plan to comply with the GDPR in future, and what needs to change.

4. Understand the personal privacy entitlement of the subjects of the information. They have rights to access it, correct mistakes, remove information, restrict its use, decline direct marketing, and copy it to their own files. What needs to change in your systems to assure these rights?

5. Issue a policy for allowing consumers access to their information you hold. You must process requests within a month, and you may not charge for the service unless your cost is excessive. You may decline unfounded or excessive demands within your policy guidelines.

6. Adapt to the requirement that you must have a legal basis for everything you do with, and to consumer data. You need to be in a position to justify your actions to the Irish Data Protection Commissioner in the event of a complaint. Having a legitimate interest is no longer sufficient.

7. Ensure that consumer consent to collect, use, and distribute their data is ?freely given, specific, informed, and unambiguous.? From 25 May 2018 onward, this consent will be your only ground to do so. You cannot force consent. Your benchmark becomes what the GDPR says.

8. Issue rules for managing data of underage subjects. This is currently under review and we are awaiting results. Put systems in place to verify age. Set triggers for where guardians must give consent. Make sure age is verifiable. Use language young people understand.

9. Introduce a culture of openness and honesty, whereby breaches of the GDPR are detected, reported, investigated, and resolved. You will have a duty to file a GDPR report with the Data Protection Commissioner within 72 hours, thus it is important to fast track the process.

10. Introduce a policy of conducting a privacy assessment before taking new initiatives. The GDPR calls for ?privacy by deign?, and we need to engineer it in. This may be the right time to appoint a data controller in your company, and start implementing the GDPR while you have time.

11. You may also need to appoint a data protection officer depending on the size of your business. Alternatively, you need to add managing data protection compliance to an employee?s duties, or appoint an external data-protection compliance consultant.

12. Finally, and you will be glad to know this is the end of the list, the GDPR has an international flavour in that multinational organisations will report into the EU Lead Supervisory Authority. This will manage the process centrally while consulting national data authorities.

The GDPR is a project we all need to complete. If we are out of line, it is in our interests to get things straightened out. Once everything is in place, the task should not be too onerous. Getting there could be the pain.

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A Small External Enterprise Development Team is Cheaper than Your Own

Time is money in the application development business. We have to get to market sooner so someone else does not gazump us, and pip us at the post. We increase the likelihood of this with every delay. Moreover, the longer your in-house team takes to get you through the swamp, the higher the project cost to you.

Of course, in theory this should not be the case. Why bring in a team from outside, and pay more to support their corporate structure? Even going for a contract micro team ought not to make financial sense, because we have to fund their mark-up and their profit taking. Our common sense tells us that this is crazy. But, hold that thought for a minute. What would you say if a small external enterprise development team was actually cheaper? To achieve that, they would have to work faster too.

The costs of an Enterprise Internal Development Team

Even if you were able to keep your own team fully occupied ? which is unlikely in the long term ? having your own digital talent pool works out expensive when you factor in the total cost. Your difficulties begin with the hiring process, especially if you do not fully understand the project topic, and have to subcontract the hiring task.

If you decide to attempt this yourself, your learning curve could push out the project completion date. Whichever way you decide to go, you are up for paying advertising, orientation training, technical upskilling, travel expenses, and salaries all of which are going to rob your time. Moreover, a wrong recruitment decision would cost three times the new employee?s annual salary, and there is no sign of that changing.

But that is not all, not all by far. If want your in-house team to keep their work files in the office, then you are going to have to buy them laptops, plus extra screens so they can keep track of what they are doing. Those laptops are going to need desks, and those employees, chairs to sit in. Plus, you are going to need expensive workspace with good security for your team?s base.

If we really wanted to lay it on, we would add software / cloud costs, telephony, internet access, and ongoing technical training to the growing pile. We did a quick scan on PayScale. The median salary of a computer programmer in Ireland is ?38,000 per year and that is just the beginning. If you need a program manager for your computer software, their salary will be almost double that at ?65,000 annually.

Advantages of R&D outsourcing

The case for a small externally sourced enterprise development team revolves around the opportunity cost ? or loss to put in bluntly ? of hiring your own specialist staff for projects. If you own a smaller business with up to 100 people, you are going to have to find work for idle digital fingers, after you roll out your in-house enterprise project. If you do not, you head down the road towards owning a dysfunctional team lacking a core, shared objective to drive them forward.

Compared to this potential extravagance, hiring a small external enterprise development team on an as-needed basis makes far more sense. Using a good service provider as a ?convenience store? drives enterprise development costs down through the floor, relative to having your own permanent team. Moreover, the major savings that arise are in your hands and free to deploy as opportunities arise. A successful business is quick and nimble, with cash flow on tap for R & D.