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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Business Turnaround Tip for a Successful MBO Turned Awry

When you acquire a company through an MBO, your hopes are always high. You know the business more than anyone else and you’ve got too much at stake to do a sloppy job. So how could things go wrong? Well sometimes they do. And if you don’t make a quick business turnaround, you could end up losing more than just your company.

If that management buyout was financed by a bank, then chances are you were required to invest a sizeable amount from your own pockets. I won’t be surprised if you even remortgaged your house for it.

Regardless of your source of funding, whether it was a bank, a venture capitalist or through a deferred consideration, the mere thought of losing your job and getting buried in enormous debt at the same time might be too much to bear. If you get too overwhelmed by your emotions and can’t think clearly, you’ll have to step out of the driver?s seat and have someone take over.

That someone can’t be a member of the management team that took part in the management buyout. Like you, he/she might be in panic mode as well. You need someone from the outside who has no emotional attachments to the company and hence can view the crisis from a clear perspective.

Here’s what’s needed:

Review and Plan

Take a closer look at all factors affecting your business: governance and organisational structures, employees, suppliers, systems and procedures, roles and responsibilities, etc. Identify potential risks and assess the likelihood of them affecting your business.

This will give a clearer picture of cause-and-effect relationships as well as the specific tasks on hand.

Thus, when it is time to draft a plan, you can do so from a well-informed standpoint. This will enable you to target specific areas of improvement and avoid pointless activities.

Assure all stakeholders

Once a watertight plan has been formulated, you will have to approach your stakeholders. They?ll need to know what your directions are. Once they’re all sold on the plan, you could implement our strategies unimpeded.

This is a very crucial part because a sceptical stakeholder can serve as a major stumbling block in our efforts to improve the situation. You need to convince your banks, sponsors, and investors in order to avoid additional financial obstacles. You need to convince your suppliers too. If they cut off or limit supply, you won’t be able to continue doing business.

Most of all, you need to persuade your staff and employees that the proposed major changes have to be carried out in order for the company to survive. You can’t run your operations without them on board.

Redesign and set up new systems and procedures

Any company requiring a turnaround will certainly have systems and procedures that are no longer working well in the current conditions and hence would require either major changes in key areas or a total revamp. You need to study personnel roles and responsibilities as well as systems and processes, including financial and IT systems, and supervise the implementation of necessary changes.

You will need to evaluate your existing IT architecture and determine how you can best maximise what you already have and propose what you think will work more efficiently for our proposed systems and procedures. Every piece of hardware or software recommended will take into consideration your present resources. There are many solutions out there, you just need to find the best fit.

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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.

Do you really need a Cloud Broker?

A cloud broker is someone who can serve as your trusted adviser when it comes to your dealings with a cloud service provider. Sort of an IT consultant who: is familiar with cloud computing, can negotiate a mutually beneficial relationship between you and a provider, and help you manage usage, performance and delivery of cloud services.?But do you need one?

Is it even time for cloud adoption?

Of course, if you haven’t even started considering moving your IT systems to the cloud, what’s the point of reading this article, right? Well, if you’re running a business in Ireland or the UK maybe you should start thinking about it. The benefits (of moving to the cloud) are simply overwhelming. But then that’s for another post.

For now, let’s just briefly talk about the rate of cloud adoption so far. This should give you an idea what other decision makers nearby think about cloud computing and what they’ve done in this regard so far.

According to research conducted by the Cloud Industry Forum (CIF), the number of first-time users of cloud computing in the United Kingdom has risen by about 27% compared to last year.

The study, which was carried out by research company Vanson Bourne and which involved IT decision-makers from both the private and public sector in UK, also showed that 61% of companies are subscribing to cloud-based services. A similar research conducted last year (2011) revealed only 48%.

In Ireland, plans are underway to adopt cloud computing. According to Pricewaterhouse Coopers, 75% of Ireland’s CIOs and IT directors are already adopting a cloud computing strategy.

Definitely, the number of cloud adopters is growing. If that number already includes your hottest competitor, then perhaps there’s no time to waste.

But while a migration to the cloud should be in your pipeline, it shouldn’t be something you should rush into. Generally speaking, there are at least three kinds of services offered by cloud service providers: IaaS (Infrastructure as a Service), PaaS (Platform as a Service), and SaaS (Software as a Service).

Some providers offer variations of these services. You might only need one type of service or a little of everything. There are also technical and regulatory compliance issues that need consideration.

Obviously, if you have no idea where or how to start, you’ll need someone who can help you. But what kind of help do you need?

Let’s proceed by talking about the kinds of services cloud brokers offer as these are obviously indicative of the needs of current cloud customers.

What cloud brokers do?

Cloud brokers offer three main types of services.

Cloud?inter-mediation

Cloud inter-mediation services are designed to add value to existing services and improve capabilities. ?Examples of cloud inter-mediation include managing access to cloud-based services, carrying out performance reporting, and establishing stronger security.

Cloud aggregation

As mentioned earlier, some cloud customers may end up subscribing to multiple cloud services; most likely from different cloud service providers. To get optimal return on their various cloud subscriptions, these customers will need to apply data integration and make these disparate systems work together. They will also have to make sure data flowing from one system to another is kept secure. This is where cloud aggregation comes into play.

Cloud arbitrage

This entails finding the best cloud service provider(s) to solve a particular problem. One example is comparing different providers offering data storage services and identifying the one offering the most competitive rates.

Other cloud arbitrage brokers develop new solutions by combining the services of different cloud service providers and then offer them to cloud customers. While there are similarities between cloud arbitrage and cloud aggregation, the former is more flexible and allows the customer to transfer from one provider to another where conditions are more favourable.

Problems a cloud broker can help you solve

Just like with natural clouds, your experiences in cloud computing won’t be all white and fluffy. You’ll also encounter gray and uncertain (or even stormy) clouds.

One major issue in cloud computing is cloud security. In fact, cloud security (or the apparent lack of it) is the one thing that’s really clouding up the sky of cloud computing. But that doesn’t mean the cloud is totally insecure. Besides, there are certain types of information that really don’t require a high level of security. These types you can easily migrate to the cloud.

For sensitive information, you really need to conduct due diligence to make sure your cloud service providers’ data centres are secure enough.

Where exactly will your data be stored? Are there enough provisions for regulatory compliance? How will your data be segregated? Does the infrastructure readily support ?data forensics? Is there a sound disaster recovery/business continuity plan? These are just some of the questions that need clear answers before you sign a contract with a cloud service provider.

Suggested reading: 9 Cloud Security Questions You Need To Ask Service Providers

Also, before you sign, you need to study the SLA (Service Level Agreement) very carefully. Look at the guaranteed uptime. Is it enough to meet your own desired service levels?

Bear in mind that the answers to these questions may be too technical. This is one of those instances when a cloud broker can come in handy. As your trusted adviser, your cloud broker can break down the technical jargon and present everything in a language that you can make intelligent decisions from.

A cloud broker will also be able to study the cloud provider’s security architecture and policies and determine whether they’re sufficient to meet your own security requirements. Basically, a cloud broker will not only help you obtain answers to your questions.

He will also know exactly what vital information to extract from providers in order to ensure that you find the best deal possible.

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