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.

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Spreadsheet woes – Burden in SOX Compliance and other Regulations

Spreadsheet Risk Issues

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Why Spreadsheets can send the pillars of Solvency II crashing down

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The Rights of Individuals Under The General Data Protection Regulation

The General Data Protection Regulation or GDPR is a European Union law reinforcing the rights of citizens concerning the confidentiality of their information, and confirming that they own it. We thought it would be interesting to examine the GDPR effective 25 May 2018 from an Irish citizen?s perspective. This article is a summary of information on the Data Protection Commissioner?s website, but as viewed through a businessperson?s lens.

How the Office Defines Data Protection

The Office believes that organisations receiving personal details have a duty to keep them private and safe. This applies inter alia to information that individuals supply to government, financial institutions, insurance companies, medical providers, telecoms services, and lenders. It also applies to information provided when they open accounts.

This information may be on paper, on computers, or in video, voice, or photographic records. The true owners of this information, the individuals have a right:

To make sure that it is factually correct
To the assurance that it is shared responsibly
That all with access only use it for stated purposes

Any organisation requesting personal information must state who they are, what the information is for, why they need to have it, and to whom else they may provide it.

Consumer Rights to Access Their Personal Information

Private persons have a right under the GDPR to a copy of all their information held or processed by a business. The regulation refers to such businesses as ?data controllers? as opposed to owners, which is interesting. They have to provide both paper and digital data, and ‘related information?.

Data controller fees for this are discretionary within limits. The request may be denied under certain circumstances. The data controller may release information about children to parents and guardians, only if it considers a minor too young to understand its significance. Other third parties such as attorneys must prove they have consent.

Consumer Rights to Port Their Data to Different Services

Since the personal information belongs to the individual, they have a right not only to access it, but also to copy or move it from one digital environment to another. The GDPR requires this be ?in a safe way, without hindrance to usability?. An application could be a banking client that wants to upload their transaction history to a third party price comparison website.

However, the right to data portability only applies to data originally provided by the consumer. Moreover, an automated method must be available for porting. Data controllers must release the information in an open format, and may not charge for the porting service.

Consumer Rights to Complain About Personal Data Abuse

Individuals have a right under the General Data Protection Regulation to have their information rectified if they discover errors. This right extends to an assurance that third parties know about the changes – and who these third party entities are. Data controllers must respond within one month. If they decline the request, they must inform the complainant of their right to further remedial action.

If a data controller refuses to release personal information to the owner, or to correct errors, then the Data Protection Office has legal power to enforce the consumer?s rights. The complainant must make full disclosure of the history of their complaint, and the steps they have taken themselves to attempt to set things right.

Further Advice on Getting Things Ready for 25 May 2018

The General Data Protection Regulation has the full force of law from 25 May 2018 onward, and supersedes all applicable Irish laws, regulations, and policies from that date. We recommend incorporating rights of data owners who are also your customers into your immediate plans. We doubt that forgetting to do so will cut much sway with the Data Commissioner. Remember, you have one month to respond to consumer requests, and only one more month to close things out subject to the matter being complex.

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

EcoVaro ? ESOS Solution on a Cloud

The UK?s Energy Saving Opportunity Scheme ? and all others in the EU stable – is bound to generate huge quantities of data beyond the reach of processing on standalone computers. This leaves some companies in the mandatory sector between a rock and a hard place. They already have to divert scarce talent to draft compliance reports. Now they face purchasing equipment with big data processing power.

The more astute are turning to cloud computing solutions like EcoVaro in increasing numbers. They are also keen to benefit from remote secure backup. .

Increasing migration to public clouds has caused a growth in niche big data consultants. EcoVaro is one of these. We want to do more than simply open up a port and leave you to become familiar with our technology. We service a growing group of companies who want us to analyse their energy usage reports, and isolate the main demand drivers so they know where to start saving.

We are consumer-centric energy consultants with the emphasis on corporates and sme?s. We offer more than just big data processing facilities. We also help set up your dashboard and are full of practical ideas you can use to start trimming energy costs right away. So please treat us as your affordable energy partner who really wants to help.

Finally, contact EcoVaro for a discussion.

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