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

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How COBIT helps you achieve SOX Compliance

First released way back in 1996, COBIT has already been around for quite a while. One reason why it never took off was because companies were never compelled to use it ? until now. Today, many CEOs and CIOs are finding it to be a vital tool for achieving SOX compliance in IT.

Thanks to SOX, COBIT (Control Objectives for Information and related Technology) is now one of the most widely accepted source of guidance among companies who have IT integrated with their accounting/financial systems. It has also gained general acceptability with third parties and regulators. But how did this happen?

Role of control frameworks in SOX compliance

You see, the Sarbanes-Oxley Act, despite having clearly manifested the urgency of establishing effective internal controls, does not provide a road map for you to follow nor does it specify a yardstick to help you determine whether an acceptable mileage in the right direction has already been achieved.

In other words, if you were a CIO and you wanted to find guidance on what steps you had to take to achieve compliance, you wouldn’t be able to find the answers in the legislation itself.

That can be a big problem. Two of your main SOX compliance obligations as a CEO or CIO is to assume responsibility in establishing internal controls over financial reporting and to certify their effectiveness. After that, the external auditors are supposed to attest to your assertions. Obviously, there has to be a well-defined basis before you can make such assertions and auditors can attest to anything.

In the language of auditors, this ?well-defined basis? is known as a control framework. Simply put, once you certify the presence of adequate internal controls in your organisation, the external auditor will ask, ?What control framework did you use??

Knowing what control framework you employed will help external auditors determine how to proceed with their evaluations and tests. For your part, a control framework can serve as a guide to help you work towards specific objectives for achieving compliance. Both of you can use it as a common reference point before drawing any conclusions regarding your controls.

But there are many control frameworks out there. What should you use?

How SOX, COSO, and COBIT fit together

Fortunately, despite SOX?s silence regarding control frameworks, you aren’t left entirely to your own devices. You could actually take a hint from the SEC and PCAOB, two of the lead organisations responsible for implementing SOX. SEC and PCAOB point to the adoption of any widely accepted control framework.

In this regard, they both highly endorse COSO, a well-established internal control framework formulated by the Committee of Sponsoring Organisations of the Treadway Commission (COSO). Now, I must tell you, if you’re looking specifically for instructions pertaining to IT controls, you won’t find those in COSO either.

Although COSO is the most established control framework for enterprise governance and risk management you’ll ever find (and in fact, it’s what we recommend for your general accounting processes), it lacks many IT-related details. What is therefore needed for your IT processes is a framework that, in addition to being highly aligned with COSO, also provides more detailed considerations for IT.

This is where COBIT fits the bill.

How COBIT can contribute to your regulatory compliance endeavors

COBIT builds upon and adheres with COSO while providing a finer grain of detail focused on IT. You can even find a mapping between COBIT IT processes and COSO components within the COBIT document itself.

Designed with regulatory compliance in mind, COBIT lays down a clear path for developing policies and good practice for IT control, thus enabling you to bridge the gap between control requirements, technical issues, and business risks.

Some of the components you’ll find in COBIT include:

IT control objectives

These are statements defining specific desired results that, as a whole, characterise a well-managed IT process. They come in two forms for each COBIT-defined IT process: a high-level control objective and a number of detailed control objectives. These objectives will enable you to have a sense of direction by telling you exactly what you need to aim for.

Maturity models

These are used as benchmarks that give you a relative measurement stating where your level of management or control over an IT process or high-level control objective stands. It serves as a basis for setting as-is and to-be positions and enables support for gap analysis, which determines what needs to be done to achieve a chosen level. Basically, if a control objective points you to a direction, then its corresponding maturity model tells you how far in that direction you’ve gone.

RACI charts

These charts tell you who (e.g. CEO, CFO, Head of Operations, Head of IT Administration) should be Responsible, Accountable, Consulted, and Informed for each activity.

Goals and Metrics

These are sets of goals along with the corresponding metrics that allow you to measure against those goals. Goals and metrics are defined in three levels: IT goals and metrics, which define what business expects from IT; process goals and metrics, which define what the IT process should deliver to support It’s objectives; and activity goals and metrics, which measure how well the process is performing.

In addition to those, you’ll also find mappings of each process to the information criteria involved, IT resources that need to be leveraged, and the governance focus areas that are affected.

Everything is presented in a logical and manageable structure, so that you can easily draw connections between IT processes and business goals, which will in turn help you decide what appropriate governance and control is needed. Ultimately, COBIT can equip you with the right tools to maintain a cost-benefit balance as you work towards achieving SOX compliance.

Which KPI?s to Use in CRM

Customer relationship management emerged in the 1980?s in the form of database marketing. In those tranquil pre-social media days, the possibility of ?managing? clients may have been a possibility although Twitter and Facebook took care of that. Modern managers face a more dynamic environment. If you are one, then what are the trends you should be monitoring yourself (as opposed to leaving it to others).

If you want to drip feed plants, you have to keep the flow of liquid regular. The same applies to drip-feed marketing. Customers are fickle dare we say forgetful. Denizon recommends you monitor each department in terms of Relationship Freshness. When were the people on your list last contacted, and what ensued from this?

Next up comes the Quality of Engagements that follow from these efforts. How often do your leads respond at all, and how many interfaces does it take to coax them into a decision? You need to relate this to response blocks and unsubscribes. After a while you will recognise the tipping point where it is pointless to continue.

Response Times relate closely to this. If your marketing people are hot then they should get a fast response to sales calls, email shots and live chats. It is essential to get back to the lead again as soon as possible. You are not the only company your customers are speaking too. Fortune belongs to the fast and fearless.

The purpose of marketing is to achieve Conversions, not generate data for the sake of it. You are paying for these interactions and should be getting more than page views. You need to drill down by department on this one too. If one team is outperforming another consider investing in interactive training.

Finally Funnel Drop-Off Rate. Funnel analysis identifies the points at which fish fall off the hook and seeks to understand why this is happening. If people click your links, make enquiries and then drift away, you have a different set of issues as opposed to if they do not respond at all.

You should be able to pull most of this information off your CRM system if it is half-decent, although you may need to trigger a few options and re orientate reporting by your people in the field. When you have your big data lined up speak to us. We have a range of data analysts brimming over with fresh ideas.

Choosing Routes for ESOS Compliance

Along the introduction of Energy Savings Opportunity Scheme in UK is the quick emergence of various companies that offer ESOS compliant services. While some energy audit providers can help, qualified businesses should understand what their compliance options are, how these routes work and learn both the pros and cons in order to carefully take their pick.

Independent ISO 50001 Certification

ISO 50001 comprises the integration and application of processes geared to motivate energy saving and overall improvement. Simply stated, it is a framework that drives the organisation’s governance to realise energy saving strategies by allocating resources and participating in energy management. The good thing about ISO 50001 is that it includes an energy review that documents ideas and opportunities to save more energy.

However, ISO 50001 does not obligate organisations to cover 90% of their overall energy consumption. In case of partial coverage, the company needs to undergo additional energy assessments to evaluate all the significant energy consumption areas.

In order for an ISO 50001 certification to be valid, it must be certified by the United Kingdom Accreditation Service (UKAS), by an accreditation body which is a member of the International Accreditation Forum, or by a body accredited by another EU member state?s national accreditation body.

Display Energy Certificates and Green Deal Assessments

These two kinds of energy assessment reports can also contribute to ESOS compliance. Both of them are carried out by qualified lead assessors and valid for 10 years. However, they are only based on the building structures and services. They do not cover the overall significant areas in energy consumption. Since these reports are valid for 10 years, they would be used for two ESOS reporting periods. Thus, they would not be as current as the ISO 50001 certification. Aside from that, the assessments are purely based on energy efficiency and anyone can qualify to use the software that produce the certifications after taking the accreditation course.

Energy Audits

A successful energy audit leads to better understanding of the company?s energy consumption, identify alternatives, determine cost-effective energy saving opportunities and stimulate energy efficiency. Energy audits are beneficial to the organisation. What makes it complex is that the organisation applying it, needs to clearly define the scope and type of energy audit to use in order to comply with ESOS. Furthermore, the organisation also has to identify the teams that would be competent enough to do the audit work for the building, transport and industrial area, respectively.

Each route is not formed equal. Thus, organisations have the option to either choose one or combine the routes and meet their company needs. The options mentioned are different approaches to ESOS and the core value is to grab the opportunity towards acquiring more savings through efficient energy system.

How Ecovaro Can Help

Ecovaro is passionate about making a difference. We are knowledgeable when it comes to ESOS legislation and regulation, ISO 50001 energy management system, DECs and Green Deal Assessments. More than that, we recognise the great impact of efficient management system to your organisation. And with this, we provide an enthusiastic team of software engineers and expert project managers to offer you our professional help at reasonable price. Ecovaro comes to you fully equipped with services tailored to your organisation’s energy management needs.

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