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

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Disadvantages of Spreadsheets – obstacles to compliance in the Healthcare Industry

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Spreadsheet woes – Burden in SOX Compliance and other Regulations

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Solutions to Password Overload

If only technologists had their way, passwords and PINs would have long been replaced with more innovative (and admittedly, better) security solutions. But such is not the case. Those alternative solutions, which include biometrics, smart cards, and password fobs, effective as they may be, are just way too expensive to implement.

So although passwords and PINs may not be here to stay, they certainly won’t be going away soon either.

Why keeping passwords in memory is no longer possible

A couple of decades ago, it would have been nearly impossible to crack an eight-character password using brute force. Today, however, advancements in computing power are rendering the typical passwords of the past easily decipherable, forcing us to come up with passwords that are not only much longer, but also much more complex and hence difficult to recall.

For instance, memorable words like your favourite character (e.g. ‘skywalker’) may have been acceptable then, but not anymore. Today?s security systems will encourage you to insert numbers or even other keyboard characters as a means to once again counter brute force. Hence, ‘sk5%ywa936lker@#’ may be more acceptable.

Remembering that one alone can be pretty daunting.

To further complicate matters, the number of applications that require passwords for access is much greater than before even for a single end user. Ordinary end users have to keep track of passwords for their email account, network login, workstation login, online services, and so on.

The burden is even greater for your IT admins, who have to remember a larger collection of passwords that protect business critical systems and applications. Clearly, the team in charge of your IT security will need a way to manage all these passwords.

Password management solutions

Existing password management solutions typically come in the form of software applications that store passwords. Basically, all you need to remember are your login details for the app a.k.a. the ?master password?. Once you’ve gained access inside, you can then retrieve any password you stored there.

Some of these apps are installed in portable devices like Pocket PCs, PDAs, or smartphones, which you would normally take along with you. For as long as the device stays with you, your passwords will be in safe hands. What’s more, you can retrieve them anywhere you go.

But obviously, there’s a problem. What if the device gets misplaced or stolen? Although the person who ends up with your device may not be able to gain access into the app and your passwords, neither will you. A better solution would therefore be an app that can be accessed anywhere but is not susceptible to getting lost.

Web-based password manager

A web-based password manager fits the bill. You don’t have to take it with you, but still you can access it almost anywhere. A typical web-based password manager will have all your passwords stored in a centralised, highly secure location.

If you want, you can even use your mobile password manager along with the web-based one. Ideally, your web-based password manager would have a copy of all the end-user passwords as well as the master passwords of your organisation.

With an easy to access but highly-secure web-based password manager, you no longer have to come up with passwords that (ironically) are supposed to be easy to remember but hard to crack at the the same time.

Furthermore, password managers are ideal for keeping passwords that have to be changed every-now-and-then; a requirement that’s becoming all too common in organisations bent on enforcing more stringent controls.

2015 ESOS Guidelines Chapter 3 ? The ESOS Assessment

ESOS operates in tandem with the ISO 50001 (Energy Management) system that encourages continual improvement in the efficient use of energy. Any UK enterprise qualifying for ESOS that has current ISO 50001 certification on the compliance date by an approved body (and that covers the entire UK corporate group) may present this as evidence of having completed its ESOS assessment. It does however still require board-level certification, following which it must notify the Environment Agency accordingly.

The Alternate ESOS Route

In the absence of an ISO 50001 energy management certificate addressing comprehensive energy use, a qualifying UK enterprise must:

Measure Total Energy Consumption in either kWh or energy spend in pounds sterling, and across the entire operation including buildings, industrial processes and transport.
Identify Areas of Significant Energy Consumption that account for at least 90% of the total. The balance falls into a de minimis group that is officially too trivial to merit consideration.
Consider Available Routes to Compliance. These could include ISO 500001 part-certification, display energy certificates, green deal assessments, ESOS compliant energy audits, self-audits and independent assessments
Do an Internal Review to make sure that you have covered every area of significant consumption. This is an important strategic step to avoid the possibility of failing to comply completely.
Appoint an Approved Lead Assessor who may be internal or external to your enterprise, but must have ESOS approval. This person confirms you have met all ESOS requirements (unless you have no de minimis exceptions).
Obtain Internal Certification by one of more board-level directors. They must certify they are satisfied with the veracity of the reports. They must also confirm that the enterprise is compliant with the scheme.
Notify the Environment Agency of Compliance within the deadline using the online notification system at snapsurveys.com as soon as the enterprise believes is fully compliant.
Assemble your ESOS Evidential Pack and back it up in a safe place. Remember, it is your responsibility to provide proof of the above. Unearthing evidence a year later it not something to look forward to.

The ESOS assessment process is largely self-regulatory, although there are checks and balances in place including lead assessor and board-level certifications. As you work through what may seem to be a nuisance remember the primary objectives. These are saving money and reducing carbon emissions. Contact Ecovaro if we can assist in any way.

Authentication and Access Control

Threats to your data can come from external or internal sources.

There are individuals who don’t have the authorisation but are driven by malicious intentions to gain access to certain information. This may refer to individuals who already belong to your organisation (but don’t have the necessary access rights) as well as those who don’t.
There are individuals who have both the authorisation and, unfortunately, the malicious intentions over certain information.
Finally, there are individuals who have the authorisation, no malicious intentions, but have accidentally exposed the information in question to those without the proper authority.

While curbing threats 2 and 3 would require other methods, threat #1 can be countered if the right authentication and access control systems are in place.

Here’s what we can do for you:

Work with your key personnel to determine who gets access to what.
Help you decide whether a single factor or a two-factor authentication (2FA) is appropriate for your organisation and recommend which factors are most suitable. Login methods may include but are not limited to the following:
- biometric devices
- Kerberos tickets
- mobile phones
- passwords
- PKI certificates
- proximity cards
- smart cards
- tokens
Install the necessary infrastructure needed for the factors chosen. For instance, if you opt to use biometrics, then biometric scanners will be installed. We’ll make sure that the authentication terminals are situated in places where achieving optimal traffic and work flow has been taken into consideration.

Other defences we’re capable of putting up include: