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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UK Government Updates ESOS Guidelines

Britain?s Environment Agency has produced an update to the ESOS guidelines previously published by the Department of Energy and Climate Change. Fortunately for businesses much of it has remained the same. Hence it is only necessary to highlight the changes here.

  1. Participants in joint ventures without a clear majority must assess themselves individually against criteria for participation, and run their own ESOS programs if they comply.
  2. If a party supplying energy to assets held in trust qualifies for ESOS then these assets must be included in its program.
  3. Total energy consumption applies only to assets held on both the 31 December 2014 and 5 December 2015 peg points. This is relevant to the construction industry where sites may exchange hands between the two dates. The definition of ?held? includes borrowed, leased, rented and used.
  4. Energy consumption while travelling by plane or ship is only relevant if either (or both) start and end-points are in the UK. Foreign travel may be voluntarily included at company discretion. The guidelines are silent regarding double counting when travelling to fellow EU states.
  5. The choice of sites to sample is at the discretion of the company and lead assessor. The findings of these audits must be applied across the board, and ?robust explanations? provided in the evidence pack for selection of specific sites. This is a departure from traditional emphasis on random.

The Environment Agency has provided the following checklist of what to keep in the evidence pack

  1. Contact details of participating and responsible undertakings
  2. Details of directors or equivalents who reviewed the assessment
  3. Written confirmation of this by these persons
  4. Contact details of lead assessor and the register they appear on
  5. Written confirmation by the assessor they signed the ESOS off
  6. Calculation of total energy consumption
  7. List of identified areas of significant consumption
  8. Details of audits and methodologies used
  9. Details of energy saving opportunities identified
  10. Details of methods used to address these opportunities / certificates
  11. Contracts covering aggregation or release of group members
  12. If less than twelve months of data used why this was so
  13. Justification for using this lesser time frame
  14. Reasons for including unverifiable data in assessments
  15. Methodology used for arriving at estimates applied
  16. If applicable, why the lead assessor overlooked a consumption profile

Check out: Ecovaro ? energy data analytics specialist 

Spreadsheet Risk Issues

It is interesting to note that the riskiness of operational spreadsheets are overlooked even by companies with high standards of risk management. Only when errors amount to actual losses do they realize that these risks have been staring them in the face all along.

Common spreadsheet risk issues

Susceptibility to trivial manual errors

Due to the fundamental structure of spreadsheets, a slight change in the formula or value in any of their inhabited cells may already affect their overall output. An

  • accidental copy-paste,
  • omission of a negative sign,
  • erroneous range selection,
  • incorrect data input or
  • unintentional deletion of a character,cell, range, column, or row

are just some of the simple errors spreadsheet users frequently encounter. Rarely are there any counter-checking controls in place in a spreadsheet-based activity and manual errors therefore easily go undetected.

Possibility of the user working on the wrong version

How do you store spreadsheet files?

Since the most common reports are usually generated on a monthly basis, users tend to store them using variations of these two configurations:

spreadsheet storage

If you notice, a user can accidentally work on the wrong version with any of these structures.

Prone to inconsistent company-wide reporting

This happens when a summary or ?final? spreadsheet is fed information by different departments coming from their own spreadsheets. Even if most of the data in their spreadsheets come from one source (the company-wide database), erroneous copy-pasting and linking, or even different interpretations of the same data can result to contradicting information in the end.

Often defenceless against unauthorised access

Some spreadsheets contain information needed by various individuals or department units in an organisation. Hence, they are often shared via email or through shared folders in a network. Now, because spreadsheets don’t normally use any access control, any user can easily open a spreadsheet file and view or modify the contents as he wishes.

Highly vulnerable to fraud

A complex spreadsheet system with zero or very minimal controls provides the perfect setting for would-be fraudsters. Hidden cells with malicious formulas and links to bogus information can go unnoticed for a long time especially if the final figures don’t deviate much from expected values.

Spreadsheet risk mitigation solutions may not suffice

Inherent complexity makes testing and logic inspection very time consuming

Deep testing can uncover possible errors hidden in spreadsheet cells and consequently mitigate risks. But spreadsheets used to support financial reporting are normally large, complex, highly-personalised and, without ample supporting documentation, understandably hard to follow.

No clear ownership of risk management responsibilities

There?s always a dilemma when an organisation starts assigning risk management responsibilities for spreadsheets. IT personnel believe users in the business side of the organisation should be responsible since they are the ones who create, edit, store, duplicate, and share the spreadsheet files. On the other hand, users believe IT should be responsible since they have always been in-charge of managing IT infrastructure, applications, and files.

To get rid of spreadsheet risks, you’ll have to get rid of spreadsheets altogether

One remedy is to have a risk management activity that involves both IT personnel and spreadsheet users. But wouldn’t you want to get rid of the complexity of having to distribute the responsibilities between the two parties instead of just one?

Learn more about Denizon’s server application solutions and how you can get rid of spreadsheet risk issues.

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

?

Advert-Book-UK

amazon.co.uk

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Advert-Book-USA

amazon.com

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Technology and process improvement

Tightening organisational flow to improve productivity and minimise costs is a growing concern for many businesses post the Global Financial Crisis. Businesses can no longer afford to waste time and personnel on inefficient processes. Organisations using either Six Sigma or Lean techniques better manage their existing resources to maximise product out-put. Both of these techniques involve considerable evaluation of current processes.

What is Six Sigma?

Six Sigma is an organisational management strategy that evaluates processes for variation. In the Six Sigma model, variation equates waste. Eliminating variation for customer fulfilment allows a business to better serve the end-user. In this thought model, the only way to streamline processes is to use statistical data. Each part of a process must be carefully recorded and analysed for variation and potential improvements. The heart of the strategy embodied by Six Sigma is mathematical. Every process is subject to mathematical analysis and this allows for the most effective problem solving.

What is a Lean Model?

Lean businesses do not rely on mathematical models for improvement. Instead, the focus is on reducing steps in the customer delivery cycle, which do not add value to the final deliverable. For example, maintaining excess inventory or dealing with shortages would both be examples of waste behaviour. Businesses that operate using Lean strategies have strong cash flow cycles. One of the best and most famous examples of Lean in action is the Toyota Production System (TPS). In this system, not only is inventory minimised, but physical movement for employees also remains sharply controlled. Employees are able to reach everything needed to accomplish their tasks, without leaving the immediate area. By reducing the amount of movement needed to work, companies also remove wasted employee time.

Industry Applications for Lean and Six Sigma

Lean businesses reduce the number of steps between order and delivery. The less inventory on hand, the less it costs a business to operate. In industries where it is possible to create to order, Lean thinking offers significant advantages. Lean is best utilised in mature businesses. New companies, operating on a youthful model, may not be able to identify wasteful processes. Six Sigma has shown its value across industries through several evolution’s. Its focus on quality of process makes it a good choice for even brand new businesses. The best use is the combination of the two strategies. With the Lean focus on speed and the Six Sigma focus on quality combined, the two organisational processes create synergy. By itself, Lean does not help create stable, repeating success. Six Sigma does not help increase speed and reduce non value-added behaviours. Combined, these two strategies offer incredible value to every business in cost savings.

Using Technology to Implement Lean Six Sigma

Automation processes represent an opportunity for businesses to implement a combination of both Lean and Six Sigma strategies. Any technology that replaces the need for direct human oversight reduces costs and increases productivity. A few examples of potentially cost saving IT solutions include document scanning, the Internet, and automated workflow systems.

  • Document Scanning – Reducing dependency on paper copies follows both Lean and Six Sigma strategies. It is a Lean addition in that it allows employees to access documents instantly from any physical location. It is Six Sigma compliant in that it allows a reduction on process variation, since there is no bottleneck on the flow of information.
  • The Internet – The automation potential offered by the Internet is limitless. Now, businesses can enter orders, manage logistics and perform customer service activities from anywhere, through a hosted portal. With instant access to corporate processes from anywhere, businesses can manage workflow globally, allowing them to realise cost savings from decentralisation.
  • Automated Work Systems – One of the identified areas of waste in any business is processing time. The faster orders are processed and delivered, the greater the profits for the company and the less the expense per order. When orders sit waiting for attention, they represent lost productivity and waste. Automated work systems monitor workflow and alert users when an item sits longer than normal. These systems can also reroute work to an available employee when the original worker is tied up.

Each of these IT solutions provides a method for businesses to either reduce the number of steps in a process or improve the quality of the process for improved customer service.

Identifying Areas for Lean Six Sigma Implementation

Knowing that improved processes result in improved profits, identifying areas for improvement is the next step. There are several techniques for creating tighter processes with less waste and higher quality. Value Stream Mapping helps business owners and managers identify areas of waste by providing a visual representation of the total process stream. Instead of improving single areas for minimal increases in productivity, VSM shows the entire business structure and flow, allowing management to target each area of slow down for maximum improvement in all areas.

Seeing the areas of waste helps management better determine how processes should work to best obtain the desired outcomes. Adding in automated processes helps with improved process management, when put in place with a complete understanding of current systems and their weaknesses. Start with mapping and gain a bird’s-eye view of the situation, in order to make the changes needed for improvement.

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