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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4 Reasons Why You Might be Missing Out on Energy Savings…

?well your company actually, although for many small-to-medium businesses it boils down to the same thing. Governments usually lag behind in terms of innovation but are beating us hands-down when it comes to going green. I have heard that private sector energy savings average less than 1% per year and I for one would not be surprised if that were true. So what is causing this rot, when we started out so enthusiastically? Here are four possibilities for you to mull over.

Your Team is Unevenly Yoked ? A pair of mismatched horses cannot pull a wagon in a straight line any more successfully than a business team can achieve its goals, if there is no agreement on priorities. While your sales team may be all for scoring green points against your competition, your accountant has a budget to balance and your operations department just wants to get on with the job.

Energy?s not in Focus ? The above may in part be due to production goals you set your department heads. Energy is not nearly as greedy as raw materials and human capital. If you tell them to cut 5%, where do you think they are going to look first? You need to put energy savings up there, and agree specific targets as you do with other primary goals.

Your Equipment Could be Over-Spec ? It is a very human thing to put more food on our plates and buy faster cars than we need. Only a few generations ago our ancestors lived through feast and famine, and the shadow of this still influences our thinking. Next time you buy equipment sit around the table and agree the decision criteria together. Then stick to them and repel all attempts at up-selling.

You Are Delegating Too Much ? Delegation is part of company culture, or if you prefer the collective way of doing things. If you delegate something completely it is akin to saying I do not care much about this, make it happen. Energy saving is a financial and moral imperative. The fact the oil price is down does not mean there is no place for sustainability on your desk (and the price is likely to be up again soon).

Governments succeed in saving energy (whereas businesses often do not) because governments have a crowd of stakeholders beating down the door and demanding progress. As business owners we are more likely to do the same when the pressure is upon us, and that pressure surely has to come from us.

Energy Management Tips

Energy management is of interest to various stakeholders; be it heads of facilities, heads of procurement, heads of environment and sustainability, financial officers, renewable energy managers and heads of energy. Some of the energy management tips that can be used to achieve considerable energy savings are:

1) Purchasing energy supplies at the lowest possible price

2) Managing energy use at peak efficiency

3) Utilising the most appropriate technology

1. Purchasing energy supplies at the lowest possible price
Purchasing energy supplies at the lowest possible price could be the starting point to great savings of energy costs. This can be achieved through switching your energy supplier. It is always advisable for companies to always take time to compare the energy tariffs to ensure they are on the best tariff and make great savings.

2. Managing energy use at peak efficiency

(a) Free help

There are some online tools that offer energy-efficiency improvements. These could come in handy in helping someone find out where to make energy-efficiency improvements.

(b) Energy monitors

An energy monitor is a gadget that estimate in real time how much energy you’re using. This can help one see where to cut back on energy consumption.

(c) Turning down thermostats

Turning down radiators especially in rooms that are rarely used/empty rooms or programming the heating to turn off when no one is there can go a long way in saving energy and energy costs.

(d) Use energy saving bulbs

Use of energy-saving light bulbs can cut down on energy usage drastically. Replacing all the light bulbs with energy-saving ones could make significant savings on energy usage and replacement costs since energy saving bulbs also have a longer life.

(e) Switching off unnecessary lights

It is also important to switch off lights that are not in use and to use the best bulb for the size of room.

(f) Sealing all heat escape routes

It is recommended that all gaps should be sealed in order to stop heat from escaping. Some of the heat escape routes are: windows, doors, chimneys and fireplaces, floorboards and skirting and loft hatches. The ways through which this can be achieved are:

? Windows- use of draught-proofing strips around the frame, brush strips work better for sash windows

? Doors – use of draught-proofing strips for gaps around the edges and brush or hinged-flap draught excluders on the bottom of doors

? Chimney and fireplace – inflatable cushions can be used to block the chimney or fit a cap over the chimney pot on fireplaces that are not used often

? Floorboards and skirting – Using a flexible silicon-based filler to fill the gaps

? Loft hatches – the use of draught-proofing strips can help to prevent hot air escaping
It is also important to consider smaller holes of air such as keyholes and letterboxes.

3. Utilising the most appropriate technology
Utilisation of technology as an energy management tool can be by way of choosing more energy efficient gadgets and by way of running technological gadgets in an energy efficient manner.

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.