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

Key Steps to Complying with ESOS

Energy Savings Opportunity Scheme has already been launched. In fact, it is by now in its initial phase. However, many businesses are still not aware of the new scheme, especially those who are covered by the qualifications for ESOS. To help them understand what they need to do in compliance to the energy efficiency strategy, here are key steps they can follow along the way.

Measure Overall Energy Consumption

The first step to complying with ESOS is to make an initial estimate of the business? energy consumption. This includes measuring the use of electricity, renewable energy, combustible fuels and all other forms of energy consumed whether in buildings, transports and industrial processes.

Three important factors to consider are the measurement units used, the reference period and quality of data. Energy units, such as MWh and GJ, or energy expenditure costs should be applied. Business enterprises should also do the initial measurement within a reference period of 12 months. Moreover, data collected should be verifiable at hand.

Identify Areas of Significant Energy Consumption

When the total energy consumption for all the activities and assets has already been estimated, it’s then time to identify what areas in the organisation comprise the significant portion of the overall energy usage. The areas recognised should cover at least 90% of the overall consumption. Meaning to say, ESOS participants have the chance to omit 10% of the energy consumption and instead focus on the 90%. This would ensure that subsequent energy audits will be cost-effective and proportionate.

Consider and Choose Compliance Routes

In order to comply with ESOS, qualified businesses should consider what compliance routes to take. These routes include taking series of energy audits, operating and implementing a certified ISO 50001 energy management system, acquiring Display Energy Certificates (DECs) and working with Green Deal assessments. Whichever route the business takes, one should maintain credible evidences, along with helpful documents, to certify their compliance.

Report the Compliance

Except when the large enterprise covers all the significant areas of energy consumption by means of ISO 50001 certification, one should appoint a lead assessor to supervise, conduct and review the organisation’s chosen ESOS compliance route. In this case, the approved assessments should then be signed off at board level to ensure that the conclusions and recommendations for energy savings are properly carried. To confirm their compliance, the business should submit a formal notification to the Environment Agency.

Because ESOS is not just an opportunity but also an obligation, it designated compliance bodies and gave them the authority to file civil penalties towards those who fail to comply with the scheme. Not only that, these appropriate authorities have the right to publish information about non-compliant enterprises including their name, details of non-compliance and corresponding penalty amount. Among these UK compliance bodies are Natural Resources Wales, Environment Agency in England, The Scottish Environment Protection Agency (SEPA) and Northern Ireland Environment Agency.

So, if you are covered with the ESOS qualifications, make sure to be informed. As the famous saying goes, ?Ignorance of the law excuses no one.? Likewise, awareness of ESOS is a responsibility every large business in UK should give importance to.

Contact Us

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

How To Get Started with your IT Compliance Efforts for SOX

There’s no question about it. For many of you top executives in the corporate world, all roads leading to a brighter future have to go through SOX compliance. And because the business processes that contribute to financial reporting (the crux of the Sarbanes-Oxley Act) are now highly reliant on IT systems, it is important to focus a good part of your attention there.

It is a long and arduous path to IT compliance, so if you don’t want your company to fall by the wayside due to inefficient utilisation of resources, it is important to set out with a plan on hand. What we have here are some vital information that will guide you in putting together a sound plan for SOX compliance of your company?s IT systems.

Why focus on IT systems for SOX compliance?

We’ll get to that. But first, let’s take up the specific portions of the Sarbanes-Oxley Act that affect information technology. These portions can be found in Section 302 and Section 404 of the act.

In simplified form, Section 302 grants the SEC (Securities and Exchange Commission) authority to come up with rules requiring you, CEOs and CFOs, to certify in each annual or quarterly financial report the following:

that you have reviewed the report;
that based on your knowledge, the report does not contain anything or leave out anything that would render it misleading;
that based on your knowledge, all financial information in the report fairly represent the financial conditions of the company;
that you are responsible for establishing internal controls over financial reporting; and
that you have assessed the effectiveness of the internal controls.

Similarly, Section 404, stated in simplified form, allows the SEC to come up with rules requiring you, CEOs and CFOs, to add an internal control report to each annual financial report stating that you are responsible for establishing internal controls over financial reporting.

You are also required to assess the effectiveness of those controls and to have a public accounting firm to attest to your assessment based upon standards adopted by the Public Company Accounting Oversight Board (PCAOB).

While there is no mention of IT systems, IT systems now play a significant role in financial reporting. Practically all of the data you need for your financial reports are stored, retrieved and processed on IT systems, so you really have to include them in your SOX compliance initiatives and establish controls on them.

Now that that’s settled, your next question could very well be: How do you know what controls to install and whether those controls are already sufficient to achieve compliance?

Finding a suitable guide for IT compliance

The two bodies responsible for setting rules and standards dealing with SOX, SEC and PCAOB, point to a well-established control framework for guidance – COSO. This framework was drafted by the Committee of Sponsoring Organisations of the Treadway Commission (COSO) and is the most widely accepted control framework in the business world.

However, while COSO is a tested and proven framework, it is more suitable for general controls. What we recommend is a widely-used control framework that aligns well with COSO but also caters to the more technical features and issues that come with IT systems.

Taking into consideration those qualifiers, we recommend COBIT. COBIT features a well thought out collection of IT-related control objectives grouped into four domains: Plan and Organise (PO), Acquire and Implement (AI), Deliver and Support (DS), and Monitor and Evaluate (ME). The document also includes maturity models, performance goals and metrics, and activity goals.

A few examples of COBIt’s detailed control objectives are:

DS4.2 – IT Continuity Plans
DS4.9 – Offsite Backup Storage
DS5.4 – User Account Management
DS5.8 – Cryptographic Key Management
DS5.10 – Network Security
DS5.11 – Exchange of Sensitive Data

By those titles alone, you can see that the framework is specifically designed for IT. But the document is quite extensive and, chances are, you won’t need all of the items detailed there. Furthermore, don’t expect COBIT to specify a control solution controls for every control objective. For example, throughout the control objective DS4 (Ensure Continuous Service), you won’t find any mention of virtualisation, which is common in any modern business continuity solution.

Basically, COBIT will tell you what you need to attain in order to achieve effective governance, management and control, but you’ll have to pick the solution best suited to reach that level of attainment.

Articles highly relevant to the one you just read:

Month End Accounting The Way It Should Be Today
Spreadsheet Woes ? Burden in SOX Compliance and Other Regulations
Spreadsheet Woes ? Limited Features For Easy Adoption of a Control Framework
How Internal Auditors Can Win The War Against Spreadsheet Fraud

Malware

In the past, viruses were created with the sole purpose of wreaking havoc on the infected systems. A large fraction of today’s malware, on the other hand, are designed to generate revenues for the creator. Spyware, botnets, and keyloggers steal information from your system or control it so that someone else can profit. In other words, the motivation for making them is now more attractive than before.

Keyloggers can reveal your usernames, passwords, PIN numbers, and other authentication information to their creators by recording your key strokes. This information can then be used for breaking into various accounts: credit cards, payment programs (like PayPal), online banks, and others. You’re right, keyloggers are among the favourite tools of individuals involved in identity theft.

Much like the viruses of old, most present day malware drain the resources, such as memory and hard disk space, of contaminated systems; sometimes forcing them to crash. They can also degrade network performance and in extreme cases, may even cause a total collapse.

If that’s not daunting enough, imagine an outbreak in your entire organisation. The damage could easily cost your organisation thousands of euros to repair. That’s not even counting yet the value of missed opportunities.

Entry points for malware range from optical disks, flash drives, and of course, the Internet. That means, your doors could be wide open to these attacks at this very moment.

Now, we’re not here to promise total invulnerability, as only an unplugged computer locked up in a vault will ever be totally safe from malware. Instead, this is what we’ll do:

Perform an assessment of your computer usage practices and security policies. Software and hardware alone won’t do the trick.
Identify weak points as well as poor practices and propose changes wherever necessary. Weak points and poor practices range from the use of perennial passwords and keeping old, unused accounts to poorly configured firewalls.
Install malware scanners and firewalls and configure them for maximal protection with minimal effect on network and system performance.
Implement regular security patches.
Conduct a regular inspection on security policy compliance as well as a review of the policies to see if they are up to date with the latest threats.
Keep an audit trail for future use in forensic activities.
Establish a risk management system.
Apply data encryption where necessary.
Implement a backup system to make sure that, in a worst case scenario, archived data is safe.
Propose data replication so as to mitigate the after effects of data loss and to ensure your company can proceed with ‘business as usual’.

Once we’ve worked with you to make all these happen, you’ll be able to sleep better.

Other defences we’re capable of putting up include: