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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Key Steps to Complying with ESOS

Energy Savings Opportunity Scheme has already been launched. In fact, it is by now in its initial phase. However, many businesses are still not aware of the new scheme, especially those who are covered by the qualifications for ESOS. To help them understand what they need to do in compliance to the energy efficiency strategy, here are key steps they can follow along the way.

Measure Overall Energy Consumption

The first step to complying with ESOS is to make an initial estimate of the business? energy consumption. This includes measuring the use of electricity, renewable energy, combustible fuels and all other forms of energy consumed whether in buildings, transports and industrial processes.

Three important factors to consider are the measurement units used, the reference period and quality of data. Energy units, such as MWh and GJ, or energy expenditure costs should be applied. Business enterprises should also do the initial measurement within a reference period of 12 months. Moreover, data collected should be verifiable at hand.

Identify Areas of Significant Energy Consumption

When the total energy consumption for all the activities and assets has already been estimated, it’s then time to identify what areas in the organisation comprise the significant portion of the overall energy usage. The areas recognised should cover at least 90% of the overall consumption. Meaning to say, ESOS participants have the chance to omit 10% of the energy consumption and instead focus on the 90%. This would ensure that subsequent energy audits will be cost-effective and proportionate.

Consider and Choose Compliance Routes

In order to comply with ESOS, qualified businesses should consider what compliance routes to take. These routes include taking series of energy audits, operating and implementing a certified ISO 50001 energy management system, acquiring Display Energy Certificates (DECs) and working with Green Deal assessments. Whichever route the business takes, one should maintain credible evidences, along with helpful documents, to certify their compliance.

Report the Compliance

Except when the large enterprise covers all the significant areas of energy consumption by means of ISO 50001 certification, one should appoint a lead assessor to supervise, conduct and review the organisation’s chosen ESOS compliance route. In this case, the approved assessments should then be signed off at board level to ensure that the conclusions and recommendations for energy savings are properly carried. To confirm their compliance, the business should submit a formal notification to the Environment Agency.

Because ESOS is not just an opportunity but also an obligation, it designated compliance bodies and gave them the authority to file civil penalties towards those who fail to comply with the scheme. Not only that, these appropriate authorities have the right to publish information about non-compliant enterprises including their name, details of non-compliance and corresponding penalty amount. Among these UK compliance bodies are Natural Resources Wales, Environment Agency in England, The Scottish Environment Protection Agency (SEPA) and Northern Ireland Environment Agency.

So, if you are covered with the ESOS qualifications, make sure to be informed. As the famous saying goes, ?Ignorance of the law excuses no one.? Likewise, awareness of ESOS is a responsibility every large business in UK should give importance to.

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How COBIT helps you achieve SOX Compliance

First released way back in 1996, COBIT has already been around for quite a while. One reason why it never took off was because companies were never compelled to use it ? until now. Today, many CEOs and CIOs are finding it to be a vital tool for achieving SOX compliance in IT.

Thanks to SOX, COBIT (Control Objectives for Information and related Technology) is now one of the most widely accepted source of guidance among companies who have IT integrated with their accounting/financial systems. It has also gained general acceptability with third parties and regulators. But how did this happen?

Role of control frameworks in SOX compliance

You see, the Sarbanes-Oxley Act, despite having clearly manifested the urgency of establishing effective internal controls, does not provide a road map for you to follow nor does it specify a yardstick to help you determine whether an acceptable mileage in the right direction has already been achieved.

In other words, if you were a CIO and you wanted to find guidance on what steps you had to take to achieve compliance, you wouldn’t be able to find the answers in the legislation itself.

That can be a big problem. Two of your main SOX compliance obligations as a CEO or CIO is to assume responsibility in establishing internal controls over financial reporting and to certify their effectiveness. After that, the external auditors are supposed to attest to your assertions. Obviously, there has to be a well-defined basis before you can make such assertions and auditors can attest to anything.

In the language of auditors, this ?well-defined basis? is known as a control framework. Simply put, once you certify the presence of adequate internal controls in your organisation, the external auditor will ask, ?What control framework did you use??

Knowing what control framework you employed will help external auditors determine how to proceed with their evaluations and tests. For your part, a control framework can serve as a guide to help you work towards specific objectives for achieving compliance. Both of you can use it as a common reference point before drawing any conclusions regarding your controls.

But there are many control frameworks out there. What should you use?

How SOX, COSO, and COBIT fit together

Fortunately, despite SOX?s silence regarding control frameworks, you aren’t left entirely to your own devices. You could actually take a hint from the SEC and PCAOB, two of the lead organisations responsible for implementing SOX. SEC and PCAOB point to the adoption of any widely accepted control framework.

In this regard, they both highly endorse COSO, a well-established internal control framework formulated by the Committee of Sponsoring Organisations of the Treadway Commission (COSO). Now, I must tell you, if you’re looking specifically for instructions pertaining to IT controls, you won’t find those in COSO either.

Although COSO is the most established control framework for enterprise governance and risk management you’ll ever find (and in fact, it’s what we recommend for your general accounting processes), it lacks many IT-related details. What is therefore needed for your IT processes is a framework that, in addition to being highly aligned with COSO, also provides more detailed considerations for IT.

This is where COBIT fits the bill.

How COBIT can contribute to your regulatory compliance endeavors

COBIT builds upon and adheres with COSO while providing a finer grain of detail focused on IT. You can even find a mapping between COBIT IT processes and COSO components within the COBIT document itself.

Designed with regulatory compliance in mind, COBIT lays down a clear path for developing policies and good practice for IT control, thus enabling you to bridge the gap between control requirements, technical issues, and business risks.

Some of the components you’ll find in COBIT include:

IT control objectives

These are statements defining specific desired results that, as a whole, characterise a well-managed IT process. They come in two forms for each COBIT-defined IT process: a high-level control objective and a number of detailed control objectives. These objectives will enable you to have a sense of direction by telling you exactly what you need to aim for.

Maturity models

These are used as benchmarks that give you a relative measurement stating where your level of management or control over an IT process or high-level control objective stands. It serves as a basis for setting as-is and to-be positions and enables support for gap analysis, which determines what needs to be done to achieve a chosen level. Basically, if a control objective points you to a direction, then its corresponding maturity model tells you how far in that direction you’ve gone.

RACI charts

These charts tell you who (e.g. CEO, CFO, Head of Operations, Head of IT Administration) should be Responsible, Accountable, Consulted, and Informed for each activity.

Goals and Metrics

These are sets of goals along with the corresponding metrics that allow you to measure against those goals. Goals and metrics are defined in three levels: IT goals and metrics, which define what business expects from IT; process goals and metrics, which define what the IT process should deliver to support It’s objectives; and activity goals and metrics, which measure how well the process is performing.

In addition to those, you’ll also find mappings of each process to the information criteria involved, IT resources that need to be leveraged, and the governance focus areas that are affected.

Everything is presented in a logical and manageable structure, so that you can easily draw connections between IT processes and business goals, which will in turn help you decide what appropriate governance and control is needed. Ultimately, COBIT can equip you with the right tools to maintain a cost-benefit balance as you work towards achieving SOX compliance.

UK Government Updates ESOS Guidelines

Britain?s Environment Agency has produced an update to the ESOS guidelines previously published by the Department of Energy and Climate Change. Fortunately for businesses much of it has remained the same. Hence it is only necessary to highlight the changes here.

  1. Participants in joint ventures without a clear majority must assess themselves individually against criteria for participation, and run their own ESOS programs if they comply.
  2. If a party supplying energy to assets held in trust qualifies for ESOS then these assets must be included in its program.
  3. Total energy consumption applies only to assets held on both the 31 December 2014 and 5 December 2015 peg points. This is relevant to the construction industry where sites may exchange hands between the two dates. The definition of ?held? includes borrowed, leased, rented and used.
  4. Energy consumption while travelling by plane or ship is only relevant if either (or both) start and end-points are in the UK. Foreign travel may be voluntarily included at company discretion. The guidelines are silent regarding double counting when travelling to fellow EU states.
  5. The choice of sites to sample is at the discretion of the company and lead assessor. The findings of these audits must be applied across the board, and ?robust explanations? provided in the evidence pack for selection of specific sites. This is a departure from traditional emphasis on random.

The Environment Agency has provided the following checklist of what to keep in the evidence pack

  1. Contact details of participating and responsible undertakings
  2. Details of directors or equivalents who reviewed the assessment
  3. Written confirmation of this by these persons
  4. Contact details of lead assessor and the register they appear on
  5. Written confirmation by the assessor they signed the ESOS off
  6. Calculation of total energy consumption
  7. List of identified areas of significant consumption
  8. Details of audits and methodologies used
  9. Details of energy saving opportunities identified
  10. Details of methods used to address these opportunities / certificates
  11. Contracts covering aggregation or release of group members
  12. If less than twelve months of data used why this was so
  13. Justification for using this lesser time frame
  14. Reasons for including unverifiable data in assessments
  15. Methodology used for arriving at estimates applied
  16. If applicable, why the lead assessor overlooked a consumption profile

Check out: Ecovaro ? energy data analytics specialist 

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