Clinical Research Data Capture Fields

1. Proposed Profile: Clinical Research Data Capture Fields

• Proposal Editor: Landen Bain, CDISC Liaison to Healthcare
• Editors: Rhonda Facile, CDASH Manager for CDISC; Gary Walker, Assoc. Dir Programming Standards, Quintiles; Bron Kisler, Terminology Manager, CDISC
• Date: January 2008
• Version: 1.0
• Domain: Patient Care Coordination

2. The Problem

While RFD simplifies data capture for investigator sites, content profiles will extend its value.

The successful demonstration of the IHE ITI integration profile Retrieve Form for Data-capture (RFD) has dramatically increased the level of interest expressed by multiple stakeholders across the healthcare value chain. Of these stakeholders, Electronic Health Record (EHR) vendors in particular are seeking to leverage RFD and the domain experience of CDISC to enable more efficient workflow when conducting clinical research within an EHR session.

The current implementation of RFD creates a data export template within an EHR session by importing a Case Report Form (CRF) from the appropriate clinical research system (Forms Manager). While the benefits of RFD have inspired the need for tighter integration, the lack of content profiles that complement RFD forces the EHR vendors to develop custom scripts to auto-populate relevant data available in the EHR into the CRF. The proposed content profile will align the data requirements of the RFD data export template with CDISC’s Clinical Data Acquisition Standards Harmonization (CDASH) effort to standardize the content of the case report form. This multi-organizational effort, endorsed by FDA, will complete version 1.0 in first quarter 2008.

This content profile will also complement the Query for Existing Data profile currently in development. A CDASH-based content profile would provide the list of data elements that an EHR should have on hand to respond to an external query from a clinical research system.

3. Key Use Case

The point of departure for this use case is a patient care site where clinical research is underway, and where RFD is already implemented. The ‘before’ state shows the use of RFD without a content profile. The ‘after’ state describes the use of RFD in concert with the proposed content profile.

Before CDASH:

A patient arrives for a visit as scheduled in the clinical trial protocol. The "study coordinator" (research nurse or clinical research coordinator) responsible for collecting clinical research data during the patient encounter, initiates an EHR session which invokes the Form Filler actor of RFD to retrieve the appropriate clinical trial CRF from the clinical research system (Form Manager). Scripts executed from within the EHR retrieve standard demographic data, but not vital signs or other necessary study-specific data which are available in the EHR. The study coordinator completes the case report form by transcribing vital signs and concomitant medication data from other screens in the EHR.

After CDASH:

A patient arrives for a visit as scheduled in the clinical trial protocol. The "study coordinator" (research nurse or clinical research coordinator) responsible for collecting clinical research data during the patient encounter, initiates an EHR session which utilizes RFD to retrieve the appropriate clinical trial CRF. The EHR identifies available CDASH data and auto-populates the retrieved form with standard demographic data, vital sign data and concomitant medication data. The study coordinator reviews the auto-populated data in the retrieved CRF, and submits the data back to the clinical research system (Forms Receiver).

4. Standards & Systems

Systems

• Participating EHRs;
• Participating Electronic Data Capture systems,
• Clinical Data Management Systems,
• Data Archiving systems;
• Biopharmaceutical sponsor protocol systems.

Standards

• CDISC standards: ODM, SDTM, CDASH, Terminology.
• W3C standards: XForm, OWL, RDF.
• HL7 standards: ICSR

5. Discussion

IHE has successfully reached the biopharmaceutical industry through a content-free integration profile, RFD. Extending the reach of RFD by binding it to clinical research specific content profiles further reinforces this cross-industry alliance. Benefits achieved will result in greater efficiencies between clinical trial sponsors, investigators and research sites, facilitating data capture and improving data quality.