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

amazon.co.uk

amazon.com

Check our similar posts

Are Target Operating Models strategic compasses?

The short answer is they usually are, because every organisation needs a road-map of where they are going. Target operating models can be complex documents with illustrative details including project management structures, special tools, implementation procedures and management metrics. They can also be simple statements, as for example Winston Churchill?s promise that ?we shall fight them on the beaches, on the landing grounds and in the fields? which gave Britain the strategic direction it needed.

Many initiatives unfortunately fail because managers are ?too busy? to bottom on what their target operating model should say, or simply don’t believe in paperwork. As a result, promising initiatives may blunder off course or die a slow death without them really noticing. We cannot manage what we cannot measure, which is where the management metrics fit in. One of my favourite quotes is ?if you don’t know where you are going any road will get you there? which is what the Cheshire Cat said to Alice in Wonderland when she got lost.

The author blundered through life without a plan because there was no one else with his particular brand of imagination. The current business climate is different because everybody is trying to ramp up, and investors want to know exactly what is going to happen to their money and by when. Hence a target operating model can be indispensable throughout a change or product cycle.

The benefits of having a measurable operations / technology plan can produce powerfully tangible results if the organisation follows through on it. Built-in metrics with milestones are powerful tool for management, and, when they map through to the company financial plan almost irreplaceable as cash-flow forecasters.

Other benefits may include:

Shorter times to market and greater agility when launching new ideas
Reduced investor risk through a predictable process that’s readily monitored
A stable operating environment where there is consensus on direction
Greater likelihood of delivering on time and leading to repeat orders
A more cost-effective process, with less risk of loss of quality and money

Although it dates back a few years the Wills UK and Ireland Retail model still provides an excellent benchmark of a target operating plan that worked. The strategic goals were exceptionally clear, and they brought in a proven project manager to help them drive the program forward.

We have delivered advanced business management services to many of our clients, and believe you will find our personalised approach time-efficient and effective too.

The General Data Protection Regulation & The Duty to use Encryption

The General Data Protection Regulation, abbreviated to GDPR, raised a storm when it arrived. In reality, it merely tightened up on existing good practice according to digital security specialists Gemalto. The right to withhold consent and to be forgotten has always been there, for example. However, the GDPR brings a free enforcement service for consumers, thus avoiding the need for third party, paid assistance.

The GDPR Bottom Lines for Data Security
Moreover, the GDPR has penalties it can apply, of the order that might have a judge choking on his wig. Under it, data security measures such as pseudonymisation (substitution of identifying fields) and encryption (encoding including password protection) have become mandatory. Businesses must further respect their client data by:

a) Storing it in a secure environment supported by robust services and systems

b) Having proven measures to restore availability and access after a breach

c) Being able to prove frequent effectiveness testing of these measures.

The General Data Protection Regulation places an onus on businesses to report any data breaches. This places us in a difficult situation. We must either face at least a wrist slap upon reporting failures. Alternatively, pay a fine of up to ?10 million, or 2% of total worldwide annual turnover.

The Engineered Weak Link in the System
Our greatest threat of breach is probably when the data leaves our secure environment, and travels across cyberspace to an employee, stakeholder, collaborator, or the client themselves. Since email became open to attack, businesses and individuals have turned to sharing platforms like Dropbox, Google Drive, Skydrive, and so on. While these do allow an additional layer of password protection, none of these has proved foolproof. The GDPR may still fine us heavily, whether or not we are to blame for the actual breach.

How Hacking is Approaching Being a Science
We may make a mistake we may regret, if we do not take hacking seriously. The 10 worst data hacks Identity Force lists are proof positive that spending lots of money does not guarantee security (any more than having the biggest stock of nuclear weapons). We have to be smart, and start thinking the way that hackers do.

Hacker heaven is finding an Experian or a Dun & Bradstreet that may have shielded 143 million, and 33 million consumer records respectively, behind a single, flimsy cyber-security door. Ignorance is no excuse for them. They should simply have known better. They should have rendered consumer data unreadable at individual record level. The hackers could have found this too demanding to unpick, and have looked elsewhere.

How Data Encryption Can Help Prevent Hackers Succeeding
Encrypting data is dashboard driven, and businesses need not concern themselves about it works. There are, however, a few basic decisions they must take:

a) Purge the database of all information held without explicit permission

b) Challenge the need for the remaining data and purge the nice-to-haves

c) Adopt a policy of encrypting access at business and customer interfaces

d) Register with three freemium encryption services that seem acceptable

e) After experimenting, sign up for a premium service and be prepared to pay

Factors to Consider When Reaching a Decision
Life Hacker?suggests the following criteria although the list is a one-size-fits-all

a) Is the system fast, simple, and easy to operate

b) Can you encrypt hidden volumes within volumes

c) Can you mass-encrypt a batch of files easily

d) Do all other files remain encrypted when you open one

e) Do files automatically re-encrypt when you close them

f) How confident are you with the vendor, on a scale of 1 to 10

It may be wise to encrypt all the files on your system, and not just your customer data. We are always open to a hack by the competition after our strategic planning. If we leave the decision up to IT, then IT, being human may take the easy way out, and encrypt as little as possible.

Contact Us

(+353)(0)1-443-3807 – IRL
(+44)(0)20-7193-9751 – UK

What GDPR Means in Practice for Irish Business

The General Data Protection Regulation (GDPR) is a European directive aimed at ring-fencing consumer data against illegal or unnecessary access. There is nothing to discuss or debate with local politicians, or the Irish Data Protection Commissioner for that matter. As a European directive, it has over-riding power. To obtain an English version, please visit this link, and select ?EN? from the table of languages.

As you reach for your tea, coffee or Guinness after sighting it, you will be glad to know the Irish Data Protection Commissioner has the lead in turning this into business English we understand. The following diagram should assist you to obtain a quick overview of the process we all have to go through. In this article, we briefly describe what is inside Boxes 1 to 12. The regulation comes into force on 25 May 2018 so we have less than a year to get ready.

The 12 Essential Steps to Implementing the General Data Protection Act

1. Create awareness among your people of what is coming their way. The GDPR has given our regulator discretion to dish out fines up to ?20,000,000 (or 4% of total annual global turnover, whichever is greater) so there is determination to make this happen.

2. Become accountable by understanding the consumer data you hold. Why are you retaining it, how did you obtain it, and why did you originally collect it. Now you know it is there, how much longer will you still need it? How secure is it in your hands, have you ever shared it?

3. Open a communication channel with your staff, your customers, and anyone else using the data. Share how you feel about how accountable you have been with the information in the past. Explain how you plan to comply with the GDPR in future, and what needs to change.

4. Understand the personal privacy entitlement of the subjects of the information. They have rights to access it, correct mistakes, remove information, restrict its use, decline direct marketing, and copy it to their own files. What needs to change in your systems to assure these rights?

5. Issue a policy for allowing consumers access to their information you hold. You must process requests within a month, and you may not charge for the service unless your cost is excessive. You may decline unfounded or excessive demands within your policy guidelines.

6. Adapt to the requirement that you must have a legal basis for everything you do with, and to consumer data. You need to be in a position to justify your actions to the Irish Data Protection Commissioner in the event of a complaint. Having a legitimate interest is no longer sufficient.

7. Ensure that consumer consent to collect, use, and distribute their data is ?freely given, specific, informed, and unambiguous.? From 25 May 2018 onward, this consent will be your only ground to do so. You cannot force consent. Your benchmark becomes what the GDPR says.

8. Issue rules for managing data of underage subjects. This is currently under review and we are awaiting results. Put systems in place to verify age. Set triggers for where guardians must give consent. Make sure age is verifiable. Use language young people understand.

9. Introduce a culture of openness and honesty, whereby breaches of the GDPR are detected, reported, investigated, and resolved. You will have a duty to file a GDPR report with the Data Protection Commissioner within 72 hours, thus it is important to fast track the process.

10. Introduce a policy of conducting a privacy assessment before taking new initiatives. The GDPR calls for ?privacy by deign?, and we need to engineer it in. This may be the right time to appoint a data controller in your company, and start implementing the GDPR while you have time.

11. You may also need to appoint a data protection officer depending on the size of your business. Alternatively, you need to add managing data protection compliance to an employee?s duties, or appoint an external data-protection compliance consultant.

12. Finally, and you will be glad to know this is the end of the list, the GDPR has an international flavour in that multinational organisations will report into the EU Lead Supervisory Authority. This will manage the process centrally while consulting national data authorities.

The GDPR is a project we all need to complete. If we are out of line, it is in our interests to get things straightened out. Once everything is in place, the task should not be too onerous. Getting there could be the pain.