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 create a custom form with Field Elite

A common requirement for most Field Service Workers is to complete various forms and paper based inspection checklists when visiting customer sites and remote area locations. Often the data collected is often used in collaboration efforts across multiple teams and organisations.

Using paper forms, binders, cameras, and filing cabinets can make this process complicated, frustrating, and often, near impossible.

If you consider that, even though we are entering the third decade of the new millennium and despite the proliferation of Smart Phones and Tablet computing an incredibly large percentage of field service teams are still making use of paper based systems!

Read more about the benefits of digital forms data collection

Field Elite Customised forms

Field Elite enables Field Service organisations to easily create their own customised forms which can be attached jobs.

The creation of forms can be done using the Web Based Administration Portal which is provided as standard to all customers when signing up for an account.

To access the form builder from Side Navigation navigate Settings –> Form Templates –> Create Form

You will then be presented with Form Builder utility which will contain an Empty Default Form and a list of fields types you are able to insert.

There are a variety of fields you can use to create all manner of forms. There is no restriction on the number of fields or field types you can choose to create forms suitable for your purpose.

If you can think it you can create it

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In the example, we’ll work through, we are going to create a Simple Conference Room Inspection Report, to be used by Facility Managers to assist in carrying room inspection reports for conference centres.

To add fields to your form simply Drag and Drop the fields onto the form.

Once you have completed adding which fields you require to your form and you are satisfied with the layout.

Select Settings tab to provide a meaningful name for your form.

You can also select a Form Layout you wish for your form. For the purpose of this post we are going to leave it as Vertical.

Once you are satisfied with your form you can select Save Form

Once your form has been saved it will be available for selection when defining jobs in the system.

Summary

It is really easy to define custom forms using the Field Elite from templates module. The Form Template module enables you to create any manner of forms your organisation may require.

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.

Project Management

In a cutthroat market, where the competition is constantly on the attack to break into your market share, implementing a project-based system can give your organisation the necessary tools to be more efficient and agile.

However, rapidly changing consumer demands, technologies and other factors make it ever more difficult to generate a strategic advantage from projects, let alone develop one. Also since a large organisation can easily end up having to manage multiple projects at the same time, the new management paradigm can appear too complex.

What your company really needs is the expertise that can guide you starting from conception and planning, down through procurement and execution in order to maximise whatever resources you have. Each move must be well thought out so that there are clear goals and objectives as well as methods to achieve them.

Programme Management

Are you running multiple projects pointing to an overall strategic direction? Then you’ll need more than just a “scaled-up” version of project management to make sure every component’s work effort is well coordinated to achieve your enterprise’s desired outcomes.

Through our expertise in programme management, we’ll work with your stakeholders, executives and clients to achieve the following:

Design a well-articulated management structure and clearly define decision-making roles & responsibilities – This will ensure decisions are made rapidly with zero to minimal overlapping issues and to promote a unified, well-synchronised advance towards the common objective.
Set objectives then make sure they are met by guiding your key personnel in coordinating activities across projects.
Design or utilise existing financial models such that they adhere to your enterprise’s financial policies.
Develop procedures for reporting expenditures specific to the programme.
Establish the programme infrastructure, including
- The appropriate technical environment and tools (e.g. hardware, software, communication, and other IT-related items)
- IT staff and administrators
Evaluate your enterprise’s current IT architecture to determine whether it will suffice to achieve your objectives. If it doesn’t, propose options you can take to meet what is required.
Plan out activities that should take place in different levels in the organisation.
Implement a periodic review of the programme progress as well as of interim results to ensure everything is aligned with the strategic outcome.

Programme and Project Reviews

Whether we’ve helped you set up your programme or you did it on your own, time will come when you’ll need to know whether everything is going as planned. If it appears like the entire programme is going smoothly, chances are, something’s going awfully wrong somewhere. Remember, even the most well-planned projects and programmes are still under the mercy of unforeseen variables.

We’ve got highly specialised reviews for either projects or an entire programme. We’ll be able to provide you answers to questions like:

Are all projects aligned with the programme’s intended direction?
Are the people working on your projects as focused with the business rationale as they have been with meeting deadlines and utilising resources?
Where are your risks and exposures? How can they be remedied?
Is the project viable at all?

We understand how your staff would want to function normally as quickly as possible. Rest assured, our programme and project reviews are conducted swiftly and efficiently so that both interruptions and oversights are brought to a minimum.

After we’re done, you can expect a detailed quantitative assessment of your programme and/or projects’ status.

Basically, we’re not here to find mistakes; we’re here to help you find ways to correct them. If a project rescue is required, we’ll be the first to lend a hand.

Project Rescue

Believe it or not, many of our clients approached us not before or during their project’s planning stages. But rather, after having gone through sloppy execution, when they end up losing control. In other words, we’re usually at the receiving end of the distress signal, after they’ve punched the panic button.

While obviously this isn’t the ideal time to seek the aid of any expert because it means you’ve incurred unnecessary losses already, all is not yet lost. If the appropriate remedial actions are taken in a timely manner, you can still achieve highly acceptable end results.

In fact, in most of our experiences with project rescue operations, we’ve been able to put projects back on track – just the way the planners wanted them to be. We’ll also help you devise airtight strategies to prevent your project from going astray again.

At the end of our project rescue,

You’ll regain complete control
Milestones will be reached as planned
Requirements will be accomplished, and
The project will be realigned with ideal business directions

Project Governance Processes

Constructing a firm underlying structure is essential in any organisation. So before we’ll institute project management, we’ll do the following first.

Set up a PMO or Project Management Office to ensure, among others, that
- Utilisation of facilities, budgets, technical support and other resources will be well coordinated
- Work products can be tracked and reviewed
- Issues regarding methodology and processes will be given appropriate attention
- Training can be organised
- Project management discipline be instilled in the IT department
Establish a steering committee to oversee the implementation of IT and business strategies
Fill up slots for a project manager, IT executive and a business sponsor and define the roles of each
Infuse project management practices to all affected units of the enterprise

Establishing PMOs, steering committees and other management structures is the easy part. Many organisations spend so much in order to create the structures related to project management, only to find out later that the effort has been all for naught. That’s why we won’t end there. Our objectives will therefore include the following:

To plant and cultivate an environment appreciative of project governance i.e. one that does not project it as just a bunch of bureaucratic processes and protocols.
To establish an organisational culture that starts at the top.
To make everyone involved understand that the power of project governance still lies in the hands of those who will ultimately implement it.

A project-driven enterprise is never propelled by a single project. Since multiple projects require a more complex governing structure, you’ll need to understand the intricacies of programme management.