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.
A mobile workforce management software is key to managing an efficient field workforce.? Managing a staff of people can be tricky in any industry. Try keeping track of employees on shifting jobsites, many whom are paid hourly or temporary workers. The added pressure of ensuring the right workers get to the right sites at the right times, but they also need to track hours, parts used, vehicles and equipment assets.
In a previous post, we defined what is an operational review and why they play a key process in the continual evolution of successful businesses.?
Operational reviews allow the organization members to evaluate their performance, according to the procedures, resources properly, timescales and budgets.
In this post, we’ll take a closer look at how to implement an operational review and the steps typically undertaken to help you and your organisation to implement an operational review.
What the steps in a Operational Review Process
There are typically six steps in an operational review that range from preparatory work conducting interviews and collecting documents to the presentation of the final written report.
An audit should be customized to meet a organisatons specific needs, so standard steps can and should only serve as a guideline.? Management and internal and external auditors should adjust the process to address the company’s particular goals and objectives.
Initial Management Meeting
Understanding the problem is the first crucial step of an operational review. This is one of major areas of discussions when the audit team meets with the management, and department heads will be asked to identify any specific areas of concern. Once the problem is identified, it would be easier to come up with workable solutions.
Conduct Interviews
The next step in the evaluation is carried out with experienced teams doing interviews and keeping close observation. Each team essentially watches how employees carry out their responsibilities. This is considered a key part of the process.
When doing the interview, it is also vital that the observing team gains the employees? trust and confidence. Likewise, the staff must be assured that whatever transpires between the team and the employee will be kept confidential. Management must therefore guarantee anonymity to anyone who offers critical information, lest employees withhold vital information and render the data gathered inaccurate.
Systems Review
Employees and management practices will be reviewed by the assessing team according to the standard policies and guidelines of the company. The effectiveness of the controls in place as well as their appropriateness to the current operating conditions will also be evaluated.
Reporting
A documentation of the data gathered and the assessment of the evaluating team, will be submitted to the management after the review process. Flow charts and written narratives of departmental activities are usually part of this report. This is also where observations and recommendations of the team will be presented to the department heads concerned.
Review Results
While the operational review is being conducted, it is important to take into account the vital factors that affect the company: the people, processes, procedures, and strategies. These four factors can determine the company?s progress in the future.
Key Areas of focus in operation reviews
At a minimum an operational review should include the following key ares of assessment
Management Control
Responsibilities, authority, and the scope in which an employee has the freedom to act must be clearly defined and documented. A complete and specific job description for instance, would give the employee a clear perspective on how he acts and functions within the company.
Boundaries should be set not only to benefit the employer but more so the employee as well.
Moral and Ethical Guidelines
Moral and ethical guidelines are just as important to ensure for a smoother employer?employee relationship. Otherwise, personal issues such as work ethics, work attitude and personal values may post problems in the long run if such guidelines are not drawn properly before relationships are established.
Processes and procedures
Evaluating processes is only beneficial if the company itself updates its processes and procedural manuals regularly, or at least when needed. Such protocols may need revision and some steps may be obsolete already. Improving a company?s processes and procedures doesn’t always entail cost. In fact, improvised procedures may even be cost-effective and could make the processes more manageable.
Communication and reporting standards
Gaps in communication could result in serious lapses in internal controls, putting the company and/or its assets at risk. This is where the importance of timely and clear communication comes in. Likewise, reports must be useful, and the flow of information and how it is processed must keep pace with the company?s growth.
Information technology (IT) and security controls can also be included under the communication clause. Proper IT security policies must be in place, state-of-the-art protection techniques employed, and everything be documented, periodically updated, and continually monitored.
Strategic planning and tactics
No company can ever be complete without its strategies. It would unwise for any organization to proceed without first knowing where it stands and what direction it wants to take. Strategic planning draws such a map. It must be aligned to the mission and vision of the company, and should also coincide with the organizational goals set. Strategic planning deals with these three key questions:
What do we do now
Whom do we do it for?
How can we overcome competition
Without clear strategic direction, expectations would likely differ between ownership and management.
Contingency planning, testing and recovery
Contingency plans must be up-to-date, and are essential to the organization. If one course of action fails, the company should have plan B, C and so on. In addition, an organization should be prepared to respond to interference’s.
This includes establishing a formal process to review transactions processing during both disruption and recovery.
Presentation of Report
Based on your objectives and our findings, we will develop detailed recommendations to improve your company?s performance and productivity. Our written report will include a list of both short-term and long-term projected improvements and courses of action, to be mutually agreed upon by both parties.
To ensure the achievement of the improvements we outlined, our team will also assist in the implementation of these modifications.
The plan has three levels of recommendations: one for executives, another for management, and a third one for staff.
The executive summary concentrates on your company?s strengths, weaknesses, opportunities and threats to its entirety. It includes recommendations for any needed changes in policy or governance.
The management plan is based on employee feedback and includes areas of immediate improvement as well as identification of potential problem areas. Concerns from the bottom level management can now be forwarded to the top level management in formal writing. Better working relationships may evolve from this, thereby setting the work environment for a higher productivity ratio.
Lastly, the staff report deals with topics like charting the hierarchy of the organization, and discussing in detail specific control objectives that are critical to the company?s mission. Part of our goal is to encourage personnel to pay close attentions to such changes, if any, as these efforts are essential if they want to bring about both organizational and personal success.
If you would like to further discuss how our operational review services can benefit your company, please feel free to contact us at your convenience to schedule an initial consultation. We?ll be more than happy to assist you.
Are your information assets enabling you to operate more cost-effectively or are they just drawing in more risks than you are actually aware of? Obviously, you now need to get a better picture of those assets to see if your IT investments are giving you the benefits you were expecting and to help you identify areas where improvements should be made.
The best way to get the answers to those questions is through technical and application assessments. In this post, we?ll identify 8 good reasons why it is now imperative to undertake such assessments.
1. Address known issues – Perhaps the most common reason that drives companies to undertake a technology/application assessment is to identify the causes of existing issues such as those related to data accessibility, hardware and software scalability, and performance.
2. Cut down liabilities and risks – Unless you know what and where the risks are, there is no way you can implement an appropriate risk mitigation strategy. A technology and application assessment will enable you to thoroughly test and examine your information systems to see where your business-critical areas and points of failure are and subsequently allow you to act on them.
3. Discover emerging risks – Some risks may not yet be as threatening as others. But it would certainly be reassuring to be aware if any exist. That way, you can either nip them in the bud or keep them monitored.
4. Comply with regulations – Regulations like SOX require you to establish adequate internal controls to achieve compliance. Other regulations call for the protection of personally identifiable information. Assessments will help you pinpoint processes that lack controls, identify data that need protection, and areas that don’t meet regulatory requirements. This will enable you to act accordingly and keep your company away from tedious, time-consuming and costly sanctions.
5. Enhance performance – Poor performance is not always caused by an ageing hardware or an overloaded infrastructure. Sometimes, the culprits are: unsuitable configuration settings, inappropriate security policies, or misplaced business logic. A well-executed assessment can provide enough information that would lead to a more cost-effective action plan and help you avoid an expensive but useless purchase.
6. Improve interoperability – Disparate technologies working completely separate from each other may be preventing you from realising the maximum potential of your entire IT ecosystem. If you can examine your IT systems, you may be able to discover ways to make them interoperate and in turn harness untapped capabilities of already existing assets.
7. Ensure alignment of IT with business goals – An important factor in achieving IT governance is the proper alignment of IT with business goals. IT processes need to be assessed regularly to ensure that this alignment continues to exist. If it does not, then necessary adjustments can be made.
8. Provide assurance to customers and investors – Escalating cases of data breaches and identity theft are making customers and investors more conscious with a company?s capability of preserving the confidentiality of sensitive information. By conducting regular assessments, you can show your customers and investors concrete steps for keeping sensitive information confidential.
Recent times have seen the advent of cloud based services and solutions where energy data is being stored in the cloud and being accessed from anywhere, anytime through remote mobile devices. This has been made possible by web-based systems that can usually bring real-time meter-data into clear view allowing for proactive business and facility management decisions. Some web based systems may even support multi utility metering points and come in handy for businesses operating multiple sites.
Whereas all this has been made possible by increased use of smart devices/ intelligent energy devices that capture data at more regular intervals; the challenge facing businesses is how to transform the large data/big volume of data into insights and action plans that would translate into increased performance in terms of increased energy efficiency or power reliability.
A solution to this dilemma facing businesses that do not know how to process big energy data, may lie in energy management software. Energy management software?s have the capability to analyse energy consumption for, electricity, gas, water, heat, renewables and oil. They enable users to track consumption for different sources so that consumers are able to identify areas of inefficiency and where they can reduce energy consumption, Energy software also helps in analytics and reporting. The analytics and reporting features that come with energy software are usually able to:
? Generate charts and graphs ? some software?s give you an option to select from different graphs
? Do graphical comparisons e.g. generate graphs of the seasonal average for the same season and day type
? Generate reports that are highly customisable
While choosing from the wide range of software available, it is important for businesses to consider software that has the capacity to support their data volume, software that can support the frequency with which their data is captured and support the data accuracy or reliability.
Energy software alone may not make the magic happen. Businesses may need to invest in trained human resources in order to realise the best value from their big energy data. Experts in energy management would then apply human expertise to leverage the data and analyse it with proficiency to make it meaningful to one?s business.
