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 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.

Field Service Organisations should use Digital Forms

For many Organisations, making use of paper based forms, is a common practice and method for collecting data and recording transactions. Whether it be for producing Quotations, Invoices or even getting sign off on completed jobs.

Paper based forms and documents have been the main stay of office communication and productivity for over 200 years. Paper-based forms are used to create anything from Invoices, Receipts, Purchase Orders, Contracts to the humble internal memo!

Paper-based forms radically improved productivity, efficiency and compliance by enabling people to create paper based instructions and enabling others to add additional information as required.

Over the past 3 decades or so, modern business environments have gradually been evolving towards the concept of the Paperless Office, resulting in the humble Paper based document migrating to a Digital Counterpart. The ease of availability of various Word Processing and Spreadsheet software products and cheap and easy data storage capacity have resulted in the Proliferation of thousands if not millions of files and documents being stored somewhere on the Company’s IT infrastructure.

People often create Digital Templates of forms that may be printed off and supplied to staff to complete using Pen and Paper or electronically. The data collation and reporting is often process

Often when conducting Operational Reviews, it is commonly found that the processing and analysing paper based forms is the least productive, efficient and profitable areas of business, although it is often vitally important.

Benefits of using digital forms for data collection

The ability to collect and analyse data effectively is increasingly important to businesses. Companies gather, examine, process and build reports on large volumes of data. Traditionally, they have deployed mail surveys, telephone interviews, door-to-door interviews as methods to collect information. With the ongoing digitisation, these procedures have become old fashioned.The digital transformation is changing many business operations at a high speed and a great deal of processes that were executed manually are now accomplished using digital methods.

Technology has had a major impact on how to approach data research and has provided researchers new tools that have transformed and improved data collection and analysis. The pace of change requires companies to be able to react quickly and adapt themselves to changing demands from customers and market conditions.

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EU Energy Efficiency Directive & UK?s ESOS

In 2012 the European Union passed its EU Energy Efficiency Directive (EED) into law. This aims to reduce overall energy consumption by 20% by 2020. It placed an obligation on member states to pass back-to-back local legislation by June 2014.

EED Guidelines

The EED provides specific guidelines it expects member nations to address. The list is long and here are a few excerpts from it:

Large companies must use energy audits to identify ways to cut their energy consumption

Small and medium companies must be incentivised to voluntarily take similar steps

Public sector bodies must purchase energy-efficient buildings, products and services

Private energy-consumers must be empowered with information to help manage demand

Energy distributors / resellers must cut their own consumption by 1.5% annually

Legislators are free to substitute green building technology e.g. through better insulation

Every year, European governments must audit 3% of the buildings they own

Definition of Energy Audit

An energy-consumption audit is a question of measuring demand throughout a supply grid, with particular attention to individual modules and high demand equipment. While this could be an exercise repeated every four years to satisfy ESOS, it makes more sense to incorporate it into the monthly energy billing cycle.

Because energy use is not consistent but varies according to production cycle, this can produce reams of printouts designed to frustrate busy managers. ecoVaro offers an inexpensive, cloud-based analytic service that effortlessly accepts client data and returns it in the form of high-level graphic summaries.

Potential ESOS Beneficiaries

As many as 9,000 UK companies are obligated to do energy audits because they employ more than 250 employees, have a balance sheet total over ?36.5m or an annual turnover in excess of ?42m. Any smaller enterprise that finds energy a significant input cost, should also consider enlisting Ecovaro to help it to:

Obtain a better understanding of the energy side of their business

Achieve energy savings and share in a estimated ?3bn bonanza to 2030

Reduce carbon emissions to help meet their CRC commitments

More About ecoVaro

We offer web-based energy management software that helps you measure and manage energy costs. This strips data from your meters and generates personalised reports on a dashboard you control. This information helps you accurately zoom in on worthwhile opportunities. With Ecovaro on your side, ESOS truly becomes an Energy Saving OPPORTUNITY Scheme.