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 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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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

Advanced Business Management

Our consultants are highly trained to provide complex management solutions and strategy planning for your business. You can count on us to improve performance and your business skills, while cutting costs.

We ensure full support in a broad range of business management areas, such as:

Business Strategy

Knowing how and when to make the right strategic move is critical to your success in today?s dynamic environment. Our Strategic Management Consultants provide solutions for a tighter integration of your vision, values, and mission statements with the strategic management process.

The result is a stronger alignment of your operating activities with your goals, and also an improved internal infrastructure to support and manage the strategic management process.

Business Process Improvements

In our years of activity, we have developed a robust process to ensure Business Process Improvements projects are implemented successfully. To achieve a positive outcome a number of factors must exist and we?ll make sure your company manages to get the right mix of: sponsorship management and commitment, process improvement goals, right motivations, cultural issues management, provision of adequate resources and funding, and availability of standards and procedures.

Performance Management

An effective performance management system integrates all aspects of the organisation from a shared vision, through a common language, and establishes a culture of accountability and results. It provides more of a holistic way of managing your organization that is more powerful than its individual parts, and without forsaking the values of the organisation.

Change Management Services

Economic downturns, fast rising new competitors, and even climate change, can force companies to scale down, engage in mergers & acquisitions, or transfer to a new location. We?ll help you through every step of the change process, from: evaluating the required change by conducting diagnostics such as change complexity, causal, structural, and context analysis, managing stakeholders including your sponsors, top executives, managers, and personnel, planning for the change, and managing the change process itself.

Project Management

Whether you need help for a single project or much more, we’ve got you covered. With us you get a coordinated, presence-of-mind approach to project management that will point all of your projects to an overall strategic direction, no matter how complex or simple these might be. Our services incorporate all project-related activities including: programme management, project risk management, project review and audit, project rescue, and project governance.

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Our resources have an MBA and/or professional accounting qualifications with an average of 10 ? 30 years of progressive work experience with public companies, in complex private equity environments, and/or privately-held middle market companies. We not only offer the most highly qualified project / interim resources to our clients, but we also allow for an interim-to-hire provision in our contracts.

It has proved mutually beneficial to our consultants and clients to have the option for longer term employment opportunities after having worked together on a project / interim basis.

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: