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.

 

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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?

 

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Spreadsheet Woes – Limited features for easy adoption of a control framework

 

Spreadsheet woes – Burden in SOX Compliance and other Regulations

 

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Why Spreadsheets can send the pillars of Solvency II crashing down

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How to Reduce Costs when Complying with SOX 404

Section 404 contains the most onerous and most costly requirements you’ll ever encounter in the Sarbanes-Oxley Act (SOX). In this article, we?ll take a closer look at the salient points of this contentious piece of legislation as it relates to IT. We?ll also explain why companies are encountering difficulties in complying with it.

Then as soon as we’ve tackled the main issues of this section and identify the pitfalls of compliance, we can then proceed with a discussion of what successful CIOs have done to eliminate those difficulties and consequently bring down their organisation’s IT compliance costs. From this post, you can glean insights that can help you plan a cost-effective way of achieving IT compliance with SOX.

SOX 404 in a nutshell

Section 404 of the Sarbanes-Oxley Act, entitled Management Assessment of Internal Controls, requires public companies covered by the Act to submit an annual report featuring an assessment of their company?s internal controls.

This ?internal control report? should state management’s responsibility in establishing/maintaining an adequate structure and a set of procedures for internal control over your company?s financial reporting processes. It should also contain an assessment of the effectiveness of those controls as of the end of your most recent fiscal year.

Because SOX also requires the public accounting firm that conducts your audit reports to attest to and report on your assessments, you can’t just make baseless claims regarding the effectiveness of your internal controls. As a matter of fact, you are mandated by both SEC and PCAOB to follow widely accepted control frameworks like COSO and COBIT. This framework will serve as a uniform guide for the internal controls you set up, the assessments you arrive at, and the attestation your external auditor reports on.

Why compliance of Section 404 is costly

Regardless which of the widely acceptable control frameworks you end up using, you will always be asked to document and test your controls. These activities can consume a considerable amount of man-hours and bring about additional expenses. Even the mere act of studying the control framework and figuring out how to align your current practices with it can be very tricky and can consume precious time; time that can be used for more productive endeavours.

Of course, there are exceptions. An organisation with highly centralised operations can experience relative ease and low costs while implementing SOX 404. But if your organisation follows a largely decentralised operation model, e.g. if you still make extensive use of spreadsheets in all your offices, then you’ll surely encounter many obstacles.

According to one survey conducted by FEI (Financial Executives International), an organisation that carried out a series of SOX-compliance-related surveys since the first year of SOX adoption, respondents with centralised operations enjoyed lower costs of compliance compared to those with decentralised operations. For example, in 2007, those with decentralised operations spent 30.1 % more for compliance than those with centralised operations.

The main reason for this disparity lies in the disorganised and complicated nature of spreadsheet systems.

Read why spreadsheets post a burden when complying with SOX and other regulations.

Unfortunately, a large number of companies still rely heavily on spreadsheets. Even those with expensive BI (Business Intelligence) systems still use spreadsheets as an ad-hoc tool for data processing and reporting.

Because compliance with Section 404 involves a significant amount of fixed costs, smaller companies tend to feel the impact more. This has been highlighted in the ?Final Report of the Advisory Committee on Smaller Public Companies? published on April 23, 2006. In that report, which can be downloaded from the official website of the US Securities and Exchange Commission, it was shown that:

  • Companies with over $5 Billion revenues spent only about 0.06% of revenues on Section 404 implementation
  • Companies with revenues between $1B – $4.9B spent about 0.16%
  • Companies with revenues between $500M – $999M spent about 0.27%
  • Companies with revenues between $100M – $499M spent about 0.53%
  • Companies with revenues less than $100M spent a whopping 2.55% on Section 404

Therefore, not only can you discern a relationship between the size of a company and the amount that the company ends up spending for SOX 404 relative to its revenues, but you can also clearly see that the unfavourable impact of Section 404 spending is considerably more pronounced in the smallest companies. Hence, the smaller the company is, the more crucial it is for that company to find ways that can bring down the costs of Section 404 implementation.

How to alleviate costs of section 404

If you recall the FEI survey mentioned earlier, it was shown that organisations with decentralised operations usually ended up spending more for SOX 404 implementation than those that had a more centralized model. Then in the ?Final Report of the Advisory Committee on Smaller Public Companies?, it was also shown that public companies with the smallest revenues suffered a similar fate.

Can we draw a line connecting those two? Does it simply mean that large spending on SOX affects two sets of companies, i.e., those that have decentralised operations and those that are small? Or can there be an even deeper implication? Might it not be possible that these two sets are actually one and the same?

From our experience, small companies are less inclined to spend on server based solutions compared to the big ones. As a result, it is within this group of small companies where you can find a proliferation of spreadsheet systems. In other words, small companies are more likely to follow a decentralised model. Spreadsheets were not designed to implement strict control features, so if you want to apply a control framework on a spreadsheet-based system, it won’t be easy.

For example, how are you going to conduct testing on every single spreadsheet cell that plays a role in financial reporting when the spreadsheets involved in the financial reporting process are distributed across different workstations in different offices in an organisation with a countrywide operation?

It’s really not a trivial problem.

Based on the FEI survey however, the big companies have already found a solution – employing a server-based system.

Typical server based systems, which of course espouse a centralised model, already come with built-in controls. If you need to modify or add more controls, then you can do so with relative ease because practically everything you need to do can be carried out in just one place.

For instance, if you need to implement high availability or perform backups, you can easily apply redundancy in a cost-effective way – e.g. through virtualisation – if you already have a server-based system. Aside from cost-savings in SOX 404 implementation, server-based systems also offer a host of other benefits. Click that link to learn more.

Not sure how to get started on a cost-effective IT compliance initiative for SOX? You might want to read our post How To Get Started With Your IT Compliance Efforts for SOX.?

Competencies, Roles and Responsibilities of Lead Assessors

Any organisation that opts for energy audits, Display of Energy Certificates and Green Deal Assessments needs a lead assessor to review the chosen ESOS compliance routes. The Derivative provides that energy audits should be carried out independently by qualified and accredited experts. Additionally, these audits should be implemented as well as supervised by independent authorities under the national legislation.

Lead assessors undertake several roles in ESOS assessments. He or she is the one responsible to take the lead of the entire assessment team, prepare the plan, conduct the meetings and submit the formal report to governing authorities. Nevertheless, selecting an appropriate lead assessor is an important element that every organisation should carefully consider.

Competencies Requirements of Lead Assessors

Lead assessors should be knowledgeable enough with in-depth expertise in carrying out energy efficiency assessment. They should also possess foundational, functional and technical competencies to deliver the task effectively. Likewise, consider the assessors? sector experiences, familiarity with your business? technologies and properties, and accreditation with prescribed standards.

As you choose your lead assessor, contemplate on the skills and qualifications that would give your organisation benefits.

Roles and Responsibilities of Lead Assessors

The business organisation is responsible for the overall legal ESOS compliance. Moreover, here are some of the roles and responsibilities that lead assessors should assume in ESOS assessments.

The lead assessor agrees on the audit methodologies that the organisation would undergo in new audits. He or she agrees with the ESOS participant regarding the audit timetable, sampling approach and visits required. It is also the lead assessor?s role to identify the opportunities on energy saving and assist in calculating the cost savings from the measures taken. During the ESOS audits, the lead assessor determines the energy use profiles, presents the recommendations and reviews the entire assessment as a whole. Furthermore, he or she should maintain the evidence pack of the ESOS to uphold the audit’s credibility, its findings and recommendations.

Finding Lead Assessors

Energy and environment professionals would only be able to demonstrate their expertise as lead assessors upon registering in a professional body accredited by the Environment Agency. Any business that needs a lead assessor is advised to check on the EA?s website to see the details of approved registers.

Lead assessors can either be in-house experts or external professionals. However, they should be able to provide proof of membership as an approved register to take the role of a lead assessor. If the organisation has an internal lead assessor, the company should then take the final ESOS assessment to two board-level directors that would sign the formal report.

Indeed, the lead assessor is an organisation’s partner when it comes to delivering great results. With good professional conduct and excellent management of an assessment team, the lead assessor can help achieve breakthrough energy efficiency strategies. More than anything else, the organisation will benefit from maximum energy savings opportunities ahead. Thus, every qualified business enterprise should invest in finding the best lead assessor to guide them towards success.

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Which Services to Share?

It often makes sense to pool resources. Farmers have been doing so for decades by collectively owning expensive combine harvesters. France, Germany, the United Kingdom and Spain have successfully pooled their manufacturing power to take on Boeing with their Airbus. But does this mean that shared services are right in every situation?

The Main Reasons for Sharing

The primary argument is economies of scale. If the Airbus partners each made 25% of the engines their production lines would be shorter and they would collectively need more technicians and tools. The second line of reasoning is that shared processes are more efficient, because there are greater opportunities for standardisation.

Is This the Same as Outsourcing?

Definitely not! If France, Germany, the United Kingdom and Spain has decided to form a collective airline and asked Boeing to build their fleet of aircraft, then they would have outsourced airplane manufacture and lost a strategic industry. This is where the bigger picture comes into play.

The Downside of Sharing

Centralising activities can cause havoc with workflow, and implode decentralised structures that have evolved over time. The Airbus technology called for creative ways to move aircraft fuselages around. In the case of farmers, they had to learn to be patient and accept that they would not always harvest at the optimum time.

Things Best Not Shared

Core business is what brings in the money, and this should be tailor-made to its market. It is also what keeps the company afloat and therefore best kept on board. The core business of the French, German, United Kingdom and Spanish civilian aircraft industry is transporting passengers. This is why they are able to share an aircraft supply chain that spun off into a commercial success story.

Things Best Shared

It follows that activities that are neither core nor place bound – and can therefore happen anywhere ? are the best targets for sharing. Anything processed on a computer can be processed on a remote computer. This is why automated accounting, stock control and human resources are the perfect services to share.

So Case Closed Then?

No, not quite. ?Technology has yet to overtake our humanity, our desire to feel part of the process and our need to feel valued. When an employee, supplier or customer has a problem with our administration it’s just not good enough to abdicate and say ?Oh, you have to speak to Dublin, they do it there?.

Call centres are a good example of abdication from stakeholder care. To an extent, these have ?confiscated? the right of customers to speak to speak directly to their providers. This has cost businesses more customers that they may wish to measure. Sharing services is not about relinquishing the duty to remain in touch. It is simply a more efficient way of managing routine matters.

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