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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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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ESOS Facts on a Page

The UK?s ESOS energy saving program stands for ?Energy Savings Opportunity Scheme?. Its purpose is to reduce demand – and hence fossil-based pollution at both ends of the supply chain. It currently applies to large UK companies only. However its guidelines are also valuable input to smaller firms voluntarily going greener.

The program threshold is 250 employees and / or turnover or at least ?UK50 million. This affects approximately 9,000 UK firms, with others below the threshold wondering whether the government plans to lower it. In essence, ESOS requires that qualifying businesses complete comprehensive audits of energy use and opportunities at least every fourth year.

The plan is carrot and stick. Compliant companies will probably uncover significant savings when they stop and measure. They may even unearth carbon credits they can sometime exchange for cash. Reactionary firms who try to duck the issue will feel Her Majesty?s wrath through stiff penalties. In time, they may find it harder to attract investors. If ESOS affects your company, then the wise thing could be complying by the first deadline of 5 December 2015.

To do so, you must conduct an energy audit and report it to the UK Environment Agency. This comprises

Measuring total energy use across processes, transport and facilities
Pie charting 90% of this to identify areas that are energy intensive
Singling out cost-effective energy-saving projects in high use areas
Submitting your report to the Environment Agency ahead of the deadline

ecoVaro recommends affected companies do not leave this to the last minute. While having ISO 50001 may exempt some from ESOS, the regulations are far from straightforward and it will take months to reach complete clarification. We would like to suggest a more balanced approach.

ESOS is a wonderful incentive to save energy costs while contributing to a better future for the kids. The Energy Savings Opportunity Scheme is precisely that. The cost of energy has crept up on us to the extent that we have to do something, government or no government.

Measuring energy consumption is as simple as installing meters at critical points in the flow, and you probably have many of them anyway. Once you have your data you no longer have to crunch the numbers. ecoVaro can do this for you and return the result in the form of handy graphs and spreadsheets.

Virtualisation

Using an IT solution that can provide the fastest (but still reliable) disaster recovery process is essential for the success of any business continuity plan. Although virtualisation is still considered leading edge technology by many business continuity specialists, it definitely brings a promise that, once fulfilled, can result in the cheapest, fastest, and most comprehensive solution for business continuity.

One great advantage of virtualisation over traditional BC (Business Continuity) methods is the relatively cheaper cost needed to achieve a certain level of business continuity assurance. Thus, more companies will find it easier to reach their required minimum for BC assurance. By contrast, some BCPs (Business Continuity Plan) based on a physical environment require companies to invest more than what they are willing to in order to reach the same minimum level of assurance.

Virtual machines, which can already encapsulate your operating systems and their corresponding applications, can be transported as a file from one machine running a compatible hypervisor to another. This makes the business continuity tasks of backup, replication, and restoration simpler and faster.

As of 2008, about 54% of IT professionals in Europe were willing to implement virtualisation within a maximum of two years. Furthermore, the expected compound annual growth rate of installed virtualised servers from 2008 to 2012 is already pegged at 33%.

If you want your organisation to take advantage of the benefits of this revolutionary technology, we’d be more than willing to help you discover what it can do for you. Then once you decide to make that transition to virtualisation, we can guide you every step of the way.

As not all applications are suited for virtualisation (e.g. some are too demanding on I/O and memory access), we’ll start by reviewing your entire IT system to see which portions can be implemented on a virtualized environment.
Using virtualisation and replication, we can conduct disaster recovery tests using up-to-date data without interrupting operations in your main IT site. Running these tests will increase your team’s preparedness and will allow you to discover possible weak points.
Provide a simple but comprehensive protection and backup system that encapsulates not only data, but also system configurations and application installations. This kind of setup allows for faster and easier disaster recovery operations. Because of these same characteristics, you can enjoy zero downtime while performing scheduled maintenance operations.
Since virtual machines are hardware-independent and transparent to operating systems, we can help you run a mix of legacy and new systems as well as open source and proprietary systems, allowing for more flexibility in your BCP budgeting.

We can also assist you with the following:

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(+44)(0)20-7193-9751 – UK

How To Get Started with your IT Compliance Efforts for SOX

There’s no question about it. For many of you top executives in the corporate world, all roads leading to a brighter future have to go through SOX compliance. And because the business processes that contribute to financial reporting (the crux of the Sarbanes-Oxley Act) are now highly reliant on IT systems, it is important to focus a good part of your attention there.

It is a long and arduous path to IT compliance, so if you don’t want your company to fall by the wayside due to inefficient utilisation of resources, it is important to set out with a plan on hand. What we have here are some vital information that will guide you in putting together a sound plan for SOX compliance of your company?s IT systems.

Why focus on IT systems for SOX compliance?

We’ll get to that. But first, let’s take up the specific portions of the Sarbanes-Oxley Act that affect information technology. These portions can be found in Section 302 and Section 404 of the act.

In simplified form, Section 302 grants the SEC (Securities and Exchange Commission) authority to come up with rules requiring you, CEOs and CFOs, to certify in each annual or quarterly financial report the following:

that you have reviewed the report;
that based on your knowledge, the report does not contain anything or leave out anything that would render it misleading;
that based on your knowledge, all financial information in the report fairly represent the financial conditions of the company;
that you are responsible for establishing internal controls over financial reporting; and
that you have assessed the effectiveness of the internal controls.

Similarly, Section 404, stated in simplified form, allows the SEC to come up with rules requiring you, CEOs and CFOs, to add an internal control report to each annual financial report stating that you are responsible for establishing internal controls over financial reporting.

You are also required to assess the effectiveness of those controls and to have a public accounting firm to attest to your assessment based upon standards adopted by the Public Company Accounting Oversight Board (PCAOB).

While there is no mention of IT systems, IT systems now play a significant role in financial reporting. Practically all of the data you need for your financial reports are stored, retrieved and processed on IT systems, so you really have to include them in your SOX compliance initiatives and establish controls on them.

Now that that’s settled, your next question could very well be: How do you know what controls to install and whether those controls are already sufficient to achieve compliance?

Finding a suitable guide for IT compliance

The two bodies responsible for setting rules and standards dealing with SOX, SEC and PCAOB, point to a well-established control framework for guidance – COSO. This framework was drafted by the Committee of Sponsoring Organisations of the Treadway Commission (COSO) and is the most widely accepted control framework in the business world.

However, while COSO is a tested and proven framework, it is more suitable for general controls. What we recommend is a widely-used control framework that aligns well with COSO but also caters to the more technical features and issues that come with IT systems.

Taking into consideration those qualifiers, we recommend COBIT. COBIT features a well thought out collection of IT-related control objectives grouped into four domains: Plan and Organise (PO), Acquire and Implement (AI), Deliver and Support (DS), and Monitor and Evaluate (ME). The document also includes maturity models, performance goals and metrics, and activity goals.

A few examples of COBIt’s detailed control objectives are:

DS4.2 – IT Continuity Plans
DS4.9 – Offsite Backup Storage
DS5.4 – User Account Management
DS5.8 – Cryptographic Key Management
DS5.10 – Network Security
DS5.11 – Exchange of Sensitive Data

By those titles alone, you can see that the framework is specifically designed for IT. But the document is quite extensive and, chances are, you won’t need all of the items detailed there. Furthermore, don’t expect COBIT to specify a control solution controls for every control objective. For example, throughout the control objective DS4 (Ensure Continuous Service), you won’t find any mention of virtualisation, which is common in any modern business continuity solution.

Basically, COBIT will tell you what you need to attain in order to achieve effective governance, management and control, but you’ll have to pick the solution best suited to reach that level of attainment.

Articles highly relevant to the one you just read:

Month End Accounting The Way It Should Be Today
Spreadsheet Woes ? Burden in SOX Compliance and Other Regulations
Spreadsheet Woes ? Limited Features For Easy Adoption of a Control Framework
How Internal Auditors Can Win The War Against Spreadsheet Fraud