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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Saving Energy Step 4 – Breathing Life into the Project

Today we consider the fourth step on the road to energy saving, when we introduce key contributors who will pull it all together. We have been on quite a journey. We started by developing a management system and then followed up with practical improvements, while challenging the assumptions behind the energy bills we may have paid unchallenged in the past.

After we knock off the big-ticket savings, managing energy becomes a process of improvement characterised by smaller increments. Kaizen is the classic model and it includes everybody in the organization from the janitor to the CEO. I inverted the pyramid deliberately, because ideas deserve considering no matter where the originator parks in the company yard.

People ? our people ?are truly central to the process. Energy adds extra leverage to their efforts, keeps them warm in winter, cool in summer and powers up the ovens in the company canteen. They are brimming over with ideas because that is the nature of being human. The best managers are those who release this potential and participate in its flowering,

It is important not to threaten job security. So many savings-driven initiatives have ended in job losses that people on the shop floor automatically suspect another round. Shrinking carbon footprints is about making the world a better place for everyone. We become more effective when we turn ?increasing profit? into making the enterprise sustainable in itself.

Engaging employees is more than office circulars and speeches at the Christmas Party. Organizations are organic places where trust grows slowly but conflict can flare in a moment. Before involving your people in your energy ?kaizan? make sure your words and intentions overlap perfectly. You will be amazed at the power you unlock in your people.

The best way I know of doing this is through your health and safety structure, which then becomes your environment, health and safety structure EHS. As you explore this idea at safety committees you find these things overlap, in the sense of creating people-centric environments at work and home.

That said, there is no magic formula for achieving employee engagement. The fact that people universally want a cleaner planet is the power to tap into. One way to form a team is to create one artificially and give it a task. The other is to work together towards a shared objective. Which one do you prefer?

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User-Friendly RASCI Accountability Matrices

Right now, you’re probably thinking that’s a statement of opposites. Something dreamed up by a consultant to impress, or just to fill a blog page. But wait. What if I taught you to create order in procedural chaos in five minutes flat? ?Would you be interested then?

The first step is to create a story line ?

Let’s imagine five friends decide to row a boat across a river to an island. Mary is in charge and responsible for steering in the right direction. John on the other hand is going to do the rowing, while Sue who once watched a rowing competition will be on hand to give advice. James will sit up front so he can tell Mary when they have arrived. Finally Kevin is going to have a snooze but wants James to wake him up just before they reach the island.

That’s kind of hard to follow, isn’t it ?

Let’s see if we can make some sense of it with a basic RASCI diagram ?

Responsibility Matrix: Rowing to the Island
Activity	Responsible	Accountable	Supportive	Consulted	Informed
Person	John	Mary	Sue	James	Kevin
Role	Oarsman	Captain	Consultant	Navigator	Sleeper

Now let’s add a simple timeline ?

Responsibility Matrix: Rowing to the Island
?	Sue	John	Mary	James	Kevin
Gives Direction	?	?	A	?	?
Rows the Boat	?	R	?	?	?
Provides Advice	S	?	?	?	?
Announces Arrival	?	?	A	C	?
Surfaces From Sleep	?	?	?	C	I
Ties Boat to Tree	?	?	A	?	?

Things are more complicated in reality ?

Quite correct. Although if I had jumped in at the detail end I might have lost you. Here?s a more serious example.

There?s absolutely no necessity for you so examine the diagram in any detail, other to note the method is even more valuable in large, corporate environments. This one is actually a RACI diagram because there are no supportive roles (which is the way the system was originally configured).

Other varieties you may come across include PACSI (perform, accountable, control, suggest, inform), and RACI-VS that adds verifier and signatory to the original mix. There are several more you can look at Wikipedia if you like.

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.