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 to Reduce Costs when Complying with SOX 404

Section 404 contains the most onerous and most costly requirements you’ll ever encounter in the Sarbanes-Oxley Act (SOX). In this article, we?ll take a closer look at the salient points of this contentious piece of legislation as it relates to IT. We?ll also explain why companies are encountering difficulties in complying with it.

Then as soon as we’ve tackled the main issues of this section and identify the pitfalls of compliance, we can then proceed with a discussion of what successful CIOs have done to eliminate those difficulties and consequently bring down their organisation’s IT compliance costs. From this post, you can glean insights that can help you plan a cost-effective way of achieving IT compliance with SOX.

SOX 404 in a nutshell

Section 404 of the Sarbanes-Oxley Act, entitled Management Assessment of Internal Controls, requires public companies covered by the Act to submit an annual report featuring an assessment of their company?s internal controls.

This ?internal control report? should state management’s responsibility in establishing/maintaining an adequate structure and a set of procedures for internal control over your company?s financial reporting processes. It should also contain an assessment of the effectiveness of those controls as of the end of your most recent fiscal year.

Because SOX also requires the public accounting firm that conducts your audit reports to attest to and report on your assessments, you can’t just make baseless claims regarding the effectiveness of your internal controls. As a matter of fact, you are mandated by both SEC and PCAOB to follow widely accepted control frameworks like COSO and COBIT. This framework will serve as a uniform guide for the internal controls you set up, the assessments you arrive at, and the attestation your external auditor reports on.

Why compliance of Section 404 is costly

Regardless which of the widely acceptable control frameworks you end up using, you will always be asked to document and test your controls. These activities can consume a considerable amount of man-hours and bring about additional expenses. Even the mere act of studying the control framework and figuring out how to align your current practices with it can be very tricky and can consume precious time; time that can be used for more productive endeavours.

Of course, there are exceptions. An organisation with highly centralised operations can experience relative ease and low costs while implementing SOX 404. But if your organisation follows a largely decentralised operation model, e.g. if you still make extensive use of spreadsheets in all your offices, then you’ll surely encounter many obstacles.

According to one survey conducted by FEI (Financial Executives International), an organisation that carried out a series of SOX-compliance-related surveys since the first year of SOX adoption, respondents with centralised operations enjoyed lower costs of compliance compared to those with decentralised operations. For example, in 2007, those with decentralised operations spent 30.1 % more for compliance than those with centralised operations.

The main reason for this disparity lies in the disorganised and complicated nature of spreadsheet systems.

Read why spreadsheets post a burden when complying with SOX and other regulations.

Unfortunately, a large number of companies still rely heavily on spreadsheets. Even those with expensive BI (Business Intelligence) systems still use spreadsheets as an ad-hoc tool for data processing and reporting.

Because compliance with Section 404 involves a significant amount of fixed costs, smaller companies tend to feel the impact more. This has been highlighted in the ?Final Report of the Advisory Committee on Smaller Public Companies? published on April 23, 2006. In that report, which can be downloaded from the official website of the US Securities and Exchange Commission, it was shown that:

  • Companies with over $5 Billion revenues spent only about 0.06% of revenues on Section 404 implementation
  • Companies with revenues between $1B – $4.9B spent about 0.16%
  • Companies with revenues between $500M – $999M spent about 0.27%
  • Companies with revenues between $100M – $499M spent about 0.53%
  • Companies with revenues less than $100M spent a whopping 2.55% on Section 404

Therefore, not only can you discern a relationship between the size of a company and the amount that the company ends up spending for SOX 404 relative to its revenues, but you can also clearly see that the unfavourable impact of Section 404 spending is considerably more pronounced in the smallest companies. Hence, the smaller the company is, the more crucial it is for that company to find ways that can bring down the costs of Section 404 implementation.

How to alleviate costs of section 404

If you recall the FEI survey mentioned earlier, it was shown that organisations with decentralised operations usually ended up spending more for SOX 404 implementation than those that had a more centralized model. Then in the ?Final Report of the Advisory Committee on Smaller Public Companies?, it was also shown that public companies with the smallest revenues suffered a similar fate.

Can we draw a line connecting those two? Does it simply mean that large spending on SOX affects two sets of companies, i.e., those that have decentralised operations and those that are small? Or can there be an even deeper implication? Might it not be possible that these two sets are actually one and the same?

From our experience, small companies are less inclined to spend on server based solutions compared to the big ones. As a result, it is within this group of small companies where you can find a proliferation of spreadsheet systems. In other words, small companies are more likely to follow a decentralised model. Spreadsheets were not designed to implement strict control features, so if you want to apply a control framework on a spreadsheet-based system, it won’t be easy.

For example, how are you going to conduct testing on every single spreadsheet cell that plays a role in financial reporting when the spreadsheets involved in the financial reporting process are distributed across different workstations in different offices in an organisation with a countrywide operation?

It’s really not a trivial problem.

Based on the FEI survey however, the big companies have already found a solution – employing a server-based system.

Typical server based systems, which of course espouse a centralised model, already come with built-in controls. If you need to modify or add more controls, then you can do so with relative ease because practically everything you need to do can be carried out in just one place.

For instance, if you need to implement high availability or perform backups, you can easily apply redundancy in a cost-effective way – e.g. through virtualisation – if you already have a server-based system. Aside from cost-savings in SOX 404 implementation, server-based systems also offer a host of other benefits. Click that link to learn more.

Not sure how to get started on a cost-effective IT compliance initiative for SOX? You might want to read our post How To Get Started With Your IT Compliance Efforts for SOX.?

Choosing Routes for ESOS Compliance

Along the introduction of Energy Savings Opportunity Scheme in UK is the quick emergence of various companies that offer ESOS compliant services. While some energy audit providers can help, qualified businesses should understand what their compliance options are, how these routes work and learn both the pros and cons in order to carefully take their pick.

Independent ISO 50001 Certification

ISO 50001 comprises the integration and application of processes geared to motivate energy saving and overall improvement. Simply stated, it is a framework that drives the organisation’s governance to realise energy saving strategies by allocating resources and participating in energy management. The good thing about ISO 50001 is that it includes an energy review that documents ideas and opportunities to save more energy.

However, ISO 50001 does not obligate organisations to cover 90% of their overall energy consumption. In case of partial coverage, the company needs to undergo additional energy assessments to evaluate all the significant energy consumption areas.

In order for an ISO 50001 certification to be valid, it must be certified by the United Kingdom Accreditation Service (UKAS), by an accreditation body which is a member of the International Accreditation Forum, or by a body accredited by another EU member state?s national accreditation body.

Display Energy Certificates and Green Deal Assessments

These two kinds of energy assessment reports can also contribute to ESOS compliance. Both of them are carried out by qualified lead assessors and valid for 10 years. However, they are only based on the building structures and services. They do not cover the overall significant areas in energy consumption. Since these reports are valid for 10 years, they would be used for two ESOS reporting periods. Thus, they would not be as current as the ISO 50001 certification. Aside from that, the assessments are purely based on energy efficiency and anyone can qualify to use the software that produce the certifications after taking the accreditation course.

Energy Audits

A successful energy audit leads to better understanding of the company?s energy consumption, identify alternatives, determine cost-effective energy saving opportunities and stimulate energy efficiency. Energy audits are beneficial to the organisation. What makes it complex is that the organisation applying it, needs to clearly define the scope and type of energy audit to use in order to comply with ESOS. Furthermore, the organisation also has to identify the teams that would be competent enough to do the audit work for the building, transport and industrial area, respectively.

Each route is not formed equal. Thus, organisations have the option to either choose one or combine the routes and meet their company needs. The options mentioned are different approaches to ESOS and the core value is to grab the opportunity towards acquiring more savings through efficient energy system.

How Ecovaro Can Help

Ecovaro is passionate about making a difference. We are knowledgeable when it comes to ESOS legislation and regulation, ISO 50001 energy management system, DECs and Green Deal Assessments. More than that, we recognise the great impact of efficient management system to your organisation. And with this, we provide an enthusiastic team of software engineers and expert project managers to offer you our professional help at reasonable price. Ecovaro comes to you fully equipped with services tailored to your organisation’s energy management needs.

Contact Us

  • (+353)(0)1-443-3807 – IRL
  • (+44)(0)20-7193-9751 – UK
Spreadsheet Risk Issues

It is interesting to note that the riskiness of operational spreadsheets are overlooked even by companies with high standards of risk management. Only when errors amount to actual losses do they realize that these risks have been staring them in the face all along.

Common spreadsheet risk issues

Susceptibility to trivial manual errors

Due to the fundamental structure of spreadsheets, a slight change in the formula or value in any of their inhabited cells may already affect their overall output. An

  • accidental copy-paste,
  • omission of a negative sign,
  • erroneous range selection,
  • incorrect data input or
  • unintentional deletion of a character,cell, range, column, or row

are just some of the simple errors spreadsheet users frequently encounter. Rarely are there any counter-checking controls in place in a spreadsheet-based activity and manual errors therefore easily go undetected.

Possibility of the user working on the wrong version

How do you store spreadsheet files?

Since the most common reports are usually generated on a monthly basis, users tend to store them using variations of these two configurations:

spreadsheet storage

If you notice, a user can accidentally work on the wrong version with any of these structures.

Prone to inconsistent company-wide reporting

This happens when a summary or ?final? spreadsheet is fed information by different departments coming from their own spreadsheets. Even if most of the data in their spreadsheets come from one source (the company-wide database), erroneous copy-pasting and linking, or even different interpretations of the same data can result to contradicting information in the end.

Often defenceless against unauthorised access

Some spreadsheets contain information needed by various individuals or department units in an organisation. Hence, they are often shared via email or through shared folders in a network. Now, because spreadsheets don’t normally use any access control, any user can easily open a spreadsheet file and view or modify the contents as he wishes.

Highly vulnerable to fraud

A complex spreadsheet system with zero or very minimal controls provides the perfect setting for would-be fraudsters. Hidden cells with malicious formulas and links to bogus information can go unnoticed for a long time especially if the final figures don’t deviate much from expected values.

Spreadsheet risk mitigation solutions may not suffice

Inherent complexity makes testing and logic inspection very time consuming

Deep testing can uncover possible errors hidden in spreadsheet cells and consequently mitigate risks. But spreadsheets used to support financial reporting are normally large, complex, highly-personalised and, without ample supporting documentation, understandably hard to follow.

No clear ownership of risk management responsibilities

There?s always a dilemma when an organisation starts assigning risk management responsibilities for spreadsheets. IT personnel believe users in the business side of the organisation should be responsible since they are the ones who create, edit, store, duplicate, and share the spreadsheet files. On the other hand, users believe IT should be responsible since they have always been in-charge of managing IT infrastructure, applications, and files.

To get rid of spreadsheet risks, you’ll have to get rid of spreadsheets altogether

One remedy is to have a risk management activity that involves both IT personnel and spreadsheet users. But wouldn’t you want to get rid of the complexity of having to distribute the responsibilities between the two parties instead of just one?

Learn more about Denizon’s server application solutions and how you can get rid of spreadsheet risk issues.

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

?

Advert-Book-UK

amazon.co.uk

?

Advert-Book-USA

amazon.com

Contact Us

  • (+353)(0)1-443-3807 – IRL
  • (+44)(0)20-7193-9751 – UK

Ready to work with Denizon?