Clinical Trial Management Adaptation to ICH E6 (R2): Good Clinical Practice
This article presents an adaptation of clinical trial management to ICH E6 (R2). A case study assesses quality risks in a clinical data management system.
ICH has issued many guidelines to standardize technical documentation for medicinal product registration and reporting. ICH topics are categorized as quality (Q), safety (S), efficacy (E), and multidisciplinary (M). ICH E6 is an efficacy guideline on good clinical practice (GCP). It covers roles and expectations for all clinical trial participants.
In the past, regulatory authorities and the pharmaceutical industry monitored quality in clinical trials using GCP standards detailed in ICH E6(R1), which was first published in 1996. 1 The ICH E6 Expert Working Group E6(R1) began to revise E6(R1) in 2014, with a focus on risk-based monitoring and quality risk management. The revised guideline, ICH E6 (R2), published in November 2016, covers risk-based monitoring based on quality risk assessment and quality risk management (QRM). 2
QRM in Clinical Trials
Complex global-scale clinical trials must be managed by prioritizing crucial tasks, which can be determined by assessing quality risks. Clinical research associates (CRAs) monitor investigator sites to ensure that management of a clinical trial by a site team is in compliance with the trial protocol and documented procedures such as patient site visit timeliness, drug accountabilities, compliance with protocols and SOPs, adverse events handling, etc.
As regulation of global clinical trials has increased, so have their development costs. They now include travel expenses, transportation costs, computerized systems implementation and operation, training and education, laboratory tests, and so on. Manpower costs include experts with therapeutic area knowledge, clinical trial design, medical writing, clinical data management, monitoring, statistical analysis, project management, communication, and negotiation.
We, the five members of the Special Interest Group No. 3 of the GAMP Community of Practice, ISPE Japan Affiliate, have adapted clinical trial management to ICH E6 (R2) by considering QRM in clinical systems implementation and operation. We conducted a case study to assess quality risks in clinical data management systems (Table A).
We assumed that clinical data management system operation has high risks related to human error such as data checking mistakes and wrong programming. Mitigation measures of these risks were mainly to eliminate human error, e. g., training data managers, double programming, and program validation. Our results indicate that this could improve oversight and management of clinical trials, allocate time and resources more efficiently, improve patient safety, and protect subject anonymity.
- 1International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use. ICH Harmonized Tripartite Guideline. “Guideline for Good Clinical Practice: E6(R1).” 10 July 1996. http://academy.gmp-compliance.org/guidemgr/files/E6_R1_GUIDELINE.PDF
- 2International Council for Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use. ICH Harmonized Guideline. “Integrated Addendum to ICH E6(R1): Guideline for Good Clinical Practice: E6(R2).” 9 November 2016. https://www.ich.org/fileadmin/Public_Web_Site/ICH_Products/Guidelines/Efficacy/E6/E6_R2__Step_4_2016_1109.pdf
Risk-Based Approach Case Study: Qrm
Introduced in ICH Q9 in 2005, 3 QRM is a framework to identify quality risks and mitigate them by taking suitable risk reduction measures. The QRM framework originated from good manufacturing practice (GMP) and fits manufacturing processes well, 3 , 4 but it is also employed in nonclinical and clinical arenas. A European Medicines Agency reflection paper illustrated QRM processes in clinical trials in 2013, 5 with a framework almost the same as the Q9 approach: critical process and data identification, risk identification, risk evaluation, risk control, risk communication, risk review, and risk reporting. Risk-based clinical operation has also been discussed by the US Food and Drug Administration (FDA). 6 , 7 The agency recommended monitoring plan factors such as scope, frequency, method, target sites, etc.
In QRM, communication and a common understanding are essential for all participants. In a clinical trial operation, for example, one quality risk is that investigators and/or site members could fail to follow the trial protocol because of misunderstanding. In such cases, one risk reduction measure could be a site-initiation meeting prior to the start of the trial. The CRA in charge should explain the trial protocol, operating procedures, medicinal products handling, and adverse events reporting to all team members. Training and review of procedures for clinical team members are additional risk reduction measures. If sponsors delegate some of these tasks to a supplier, risks can be mitigated by confirming the supplier’s quality management system (QMS) before the trial begins.
Risk mitigation programs must be monitored and reviewed to evaluate their effectiveness and appropriateness. They should be revised, if necessary, to mitigate newly identified risks.
Clinical Systems
In many clinical trials, data is collected and managed through web-based clinical data management systems (CDMS) with electronic data capture (EDC). Clinical project management is conducted with the assistance of clinical trial management systems (CTMS). Both CDMS and CTMS are usually constructed using configurable software—category 4 software as defined in the GAMP® 5 Guide.8 A clinical system user can perform a system validation as shown in the GAMP® 5 Guide. 8 , 9 Risks related to data integrity should also be considered. 10
By leveraging information technologies such as EDC and cloud computing services, CRAs and data managers may conduct central monitoring and/or remote monitoring. CRAs should generate their monitoring plan prior to their first site visit. If an investigator doesn’t have enough experience in conducting a clinical trial, for example, the CRA would need to visit the site frequently. Monitoring frequency should be documented in the monitoring plan.
When a CRA goes through a trial database on data management system with EDC function, they can determine whether subjects are coming to the investigator sites on schedule or not. If no protocol violation is observed through the database checking, the CRA doesn’t need to visit the site as frequently. If some protocol violations are observed, however, the CRA should go to the site, meet the site team members, and provide a comprehensive explanation of the protocol again in person.
SOPs
According to ICH E6(R2), sponsor standard operating procedures (SOPs) should include system setup, installation, use, validation, functionality testing, data collection and handling, maintenance, security measures, change control, data backup, recovery, contingency planning, and decommissioning. 2 Nowadays it is common for sponsors to delegate their clinical operation tasks to clinical research organizations, technical suppliers, and/or other third parties. 11 , 12 When a clinical system is set up as a cloud computing service or software as a service (SaaS), some technical activities can be performed by the SaaS supplier. We identified task allocation to sponsors and SaaS service suppliers in Table B. In these cases, some risks can be mitigated by confirming the supplier’s QMS beforehand.
Future Clinical Trials
To deal with the effects of recent technology on clinical trial categorization, a January 2017 ICH reflection paper proposed an eventual renovation of ICH E6 and modernization of ICH E8. E8 was first issued in 1997 to clarify general considerations for clinical trials, focus on clinical trial categorization and timing, 13 and serve as a guide to other ICH standards on clinical trials. 14 Citing the Declaration of Helsinki, E8 also emphasizes protection of trial subjects and scientific approach in design and analysis. 15 One concern, for example, is that in the future investigators could use a database investigation to conduct a clinical “trial” and generate evidence without patients’ consent or participation. 16 , 17 , 18
Process | Steps | Possible error and risk | Mitigation measure(s) | Supplier* | |
---|---|---|---|---|---|
1-1 | Clinical database setup and trial preparation |
Setup according to trial protocol; data definition |
Poor data definition | Training and skill improvement of data manager |
|
1-2 | Setup according to trial protocol; interface preparation and eCRF preparation | Data entry is difficult because of poorly organized eCRF | Training and skill improvement of data manager |
||
1-3 | Setup according to trial protocol; edit checking (univariate) |
Mistake on edit checking program | • Training and skill improvement of clinical programmer • Double programming |
||
1-4 | Setup according to trial protocol; edit checking (multivariate) |
Mistake on edit checking program | • Training and skill improvement of clinical programmer • Double programming |
||
1-5 | General | Bugs with the software | Confirmation of supplier’s QMS** | Software developer |
|
1-6 | Site-initiation meeting | Team members are reluctant to attend the meeting | • Meeting scheduling • Communication skill improvement of clinical leader |
||
2-1 | Clinical data processing | Investigator input data to eCRF | Data entry error | • Annotated CRF • Training for investigator • Frequent monitoring |
|
2-2 | Investigator input data to eCRF | Data entry by unauthorized access or identity spoofing | Training for investigator and co-worker(s) | ||
2-3 | Investigator input data to eCRF | Data alteration by unauthorized access | Confirmation of supplier’s QMS | Data center provider |
|
2-4 | Automatic edit checking during data entry via computer program |
Computer programming error | Program validation | ||
2-5 | Data transfer from eCRF database server to central server at Sponsor |
Transfer failure because of computer programming error |
Program validation | ||
2-6 | Data checking by data manager with computer program |
Checking mistake because of computer programming error | Program validation | ||
2-7 | Data checking by data manager manually | Checking mistake by data manager | Skill improvement of data manager | ||
2-8 | Source document verification by CRA | Discrepancy unsolved because of wrong procedures | • Skill improvement of CRA • Manager to supervise CRA’s operation |
||
3-1 | Data acquisition from central lab | Lab test results report delivered to investigator |
Test results with mistake because of central lab system error | • Reporting system maintenance • Confirmation of supplier’s QMS |
Central lab |
3-2 | Investigator input comments of lab data to eCRF |
Data entry error | • Annotated CRF • Source document verification by CRA |
||
3-3 | Investigator input comments of lab data to eCRF |
Data entry by unauthorized access or identity spoofing | Training for investigator and co-worker(s) | ||
3-4 | Investigator input comments of lab data to eCRF |
Data alteration by unauthorized access | High security | ||
3-5 | Lab test results to be downloaded from lab server to sponsor server |
Download failure because of computer programming error | Program validation | ||
3-6 | Lab test results to be downloaded from lab server to sponsor server |
Operation mistake | Training for operator | ||
4-1 | Patient-related data acquisition via ePRO |
Patients input relevant data electronically to ePRO device |
Operation mistake | Training for patient | |
4-2 | Date transfer from ePRO device to third-party server |
Transfer failure because of computer programming error |
• Program validation • Confirmation of supplier’s QMS |
ePRO device provider |
|
4-3 | Date transfer from third-party server to sponsor server |
Transfer failure because of computer programming error |
• Program validation • Confirmation of supplier’s QMS |
Data center provider |
|
5-1 | Clinical data processed to clinical study report and M5 dossier |
Dataset for statistical analysis generated by data manager with computer program |
Dataset generation failure because of computer programming error |
• Program validation • Training and skill improvement of clinical programmer |
|
5-2 | Statistical analysis results, subjects list, tables, and figures to be generated by statistician with computer program |
Statistical analysis failure because of computer programming error |
• Program validation • Training and skill improvement of clinical programmer |
||
5-3 | Clinical study report preparation | Documentation error | Double-checking | ||
5-4 | M5 dossier preparation based on clinical study report |
Publication error | Double-checking | ||
6-1 | Technical maintenance |
Data backup or server mirroring | Backup failure because of technical error | Confirmation of supplier’s QMS | Data center provider |
*Relevant supplier is indicated if applicable ** Supplier’s QMS may be confirmed during supplier assessment
eCRF: electronic case report form QMS: quality management system CRA: clinical research associate PRO: patient reported outcome
Obviously it is important for researchers to utilize a well-organized and reliable medical database. The National Cancer Institute’s SEER (Surveillance, Epidemiology, and End Results) program, for example, is a source for cancer statistics in the United States that has generated many successful studies. Database study with real-world data is quite new and likely to increase in the future.
The General Data Protection Regulation (GDPR)19 focuses on patient information handling and anonymization in the EU. It became effective in May 2018, but anonymization rules have not yet been clearly defined nor agreed globally. Under GCP, subject identification codes are commonly used for anonymization in clinical trial operations, but it is unknown whether this is sufficient under the GDPR.
Conclusion
We discussed and investigated the adaptation of clinical trial management and system to the ICH E6 (R2) guideline. The ICH E6 (R2) guideline affects both clinical operation and clinical systems validation activities. We conducted a case study to assess quality risks of clinical data management system and its operation. Training for clinical team members and operation procedures review are important risk-reduction measures. A sponsor may delegate some tasks related to clinical system to a supplier, relevant risks can be mitigated via ensuring the supplier’s QMS. The supplier’s QMS should be confirmed through supplier assessment beforehand.
Item* | Task allocation | |
---|---|---|
Cloud computing (SaaS) | System on the premises | |
System setup | Service supplier | Sponsor |
System installation | Service supplier | Sponsor |
System use | Sponsor | Sponsor |
System validation | Sponsor | Sponsor |
Functionality testing | Service supplier mainly Sponsor partially (only functions to be used in their business processes) |
Sponsor |
Data collection and handling | Sponsor | Sponsor |
System maintenance | Service supplier | Sponsor |
System security measures | Sponsor | Sponsor |
Change control | Service supplier mainly | Sponsor |
Data backup | Service supplier mainly | Sponsor |
Recovery | Service supplier mainly | Sponsor |
Contingency planning | Sponsor | Sponsor |
Decommissioning | Service supplier mainly | Sponsor |
* Items are cited from ICH E6(R2) 2
- 3 a b International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use. “Quality Risk Management: Q9.” 9 November 2005.http://www.ich.org/fileadmin/Public_Web_Site/ICH_Products/Guidelines/Quality/Q9/Step4/Q9_Guideline.pdf
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- 2 a b
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Acknowledgment
We appreciate the kind support of the ISPE Japan Affiliate officers.