Tag Archive | CROs

Leveraging Technology to Improve Patient Recruitment for Clinical Trials

I was asked to respond to a costumer inquiry recently to help them with providing a solution to improve their patient recruitment in clinical trials. Initially, I thought this must be a question to one of our experts in our CRO. However, I kept thinking about it and realized there isn’t a silver bullet that would solve this problem. There is no commercial off-the-shelf solution to fix this problem. Sponsors, CROs, Site Coordinators, PIs and other stakeholders involved in the clinical research have been struggling to address this situation but it is still a challenge and is the root cause of delays in clinical trials which will result in increased and lower Returns on Investment (ROI).

Discovery and development of medical products take a long time and consume lot of resources (Effort & Cost) from sponsors from molecule to patient. This involves discovery of the molecule to pre-clinical and clinical development to marketing & sales. A lot of these resources are typically spent in late stage (Phase III) of clinical trials. One of the root causes for delays in clinical trials in phase III is delay in recruiting the patients that meet the inclusion criteria of the protocol. Another key concern is patient drop out during the course of the trial. These issues not only delay the trial but also force the sponsors and CROs to consider changes to the protocol or force them to take alternative steps to ensure the necessary patient population is recruited to continue the trial.

Adherence rates across the duration of therapy

Adherence rates across the duration of therapy

According to a report on Patient Adherence by Capgemini consulting [1], “Patient adherence levels vary between 50% for depression to 63% for enlarged prostate. On average, adherence levels drop over the course of the patient journey from 69% of patients filling their first prescription to 43% continuing their treatment as prescribed after 6 months.”

Also, if you notice in the attached diagram, 31% of the patients recruited will not last until they fill their prescription. Further, by the sixth month almost 57% patients do not show up for their refills. At this rate, in order to continue the trial, the sponsor has to continue to recruit patients during the course of the trial. This recruitment due to a drop out comes at a cost. The report has also identified that the cost of recruiting a new patient is 6 times the cost spent by sponsors to retain an existing patient.

So, what are the sponsors/CROs doing to improve the patient recruitment and reduce the drop outs? The key to fixing any problem is identifying the root cause. For this problem, there are multiple areas of failure and hence requires a comprehensive, multi-pronged strategy to fix the problems.  Some of the best practices being adopted by sponsors and/or CROs include:

  • Comprehensive and incremental approach to integrated solutions rather than silos  by leveraging :

–          Patient registries

–          Better communication between patients and clinicians

–          Electronic records

–          Better engagement of physicians

  • Refine Site selection

–          Analysis to select better performing sites

  • Patient centric recruitment process

–          Simplify informed consent process (move to informed choice)

  • Collaborative approach to Protocol design

–          Engaging Principal Investigators (PIs) in protocol design by research coordinators

  • Improve patient retention

–          Better follow-up systems to increase adherence

–          Enhanced post-trial engagement

In order to implement these best practices sponsors can adopt technology solutions like:

  1. Create strategy to improve the recruitment process by leveraging technology solutions
  2. Analyze site performance and select high performing sites and drop out non-performing sites
  3. Patient Recruitment Systems to search and match protocol eligibility criteria with patient’s available Electronic Health Records (EMRs, Narratives, Health Insurance and Claims Documents)
  4. Social Media tools to target patient communities to identify potential subjects from the available patient population
  5. Social Media tools to gauge trial buzz in patient and physician community
  6. Study & Investigator Portals to enhance engagement and collaboration between study coordinators and Principal Investigators
  7. Mobile Trial Adherence Systems to alert and notify patients of visits and other trial compliance activities to reduce drop outs
  8. Key Opinion Leader portals to better engage physicians
  9. Analytics to identify potential subjects, site initiation process and performance, patient recruitment effectiveness, patient drop out alerts etc.
  10. Advanced analytics to simulate recruitment performance based on historical data and thus tailoring recruitment strategy based on sites and other factors

Despite all these best practices and solutions, will be able to help the sponsors and CROs in:

  • Collecting historical and real time operational and scientific data
  • Performing objective analysis of data
  • Visualization of such performance
  • Identifying the bottlenecks and root causes for the problems
  • Helping in making decisions to select the right sites, recruit the right patients, avoid costly drop outs and improve the collaboration and communication among Patients, Primary Investigators and other stakeholders.

I will be writing about each solution in my “Top 10” list above. As I mentioned in the beginning of this post, there is no silver bullet for this problem. A strategic and integrated approach to create solutions that will aid in collecting, analyzing and decision making is the only way to solve this problem.

As always, please let me know your feedback. If you have more insights into the problem or solutions, I will be more than glad to discuss with you and also post some of the inferences in a subsequent post, as promised. Happy Reading!!!

References:

  1. “Patient Adherence: The Next Frontier in Patient Care – Vision & Reality, 9th Edition Global Research Report”  by Capgemini Consulting
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Can “Clinical Data Integration on the Cloud” be a reality?

The story I am about to tell is almost 8 years old. I was managing software services delivery for a global pharmaceutical company from India. This was a very strategic account and the breadth of services covered diverse systems and geographies. It is very common that staff from the customer organization visit our delivery centers (offsite locations) to perform process audits, governance reviews and to meet people in their extended organizations.

During one such visit a senior executive noticed that two of my colleagues, sitting next to each other, supported their system (two different implementations of the same software) across two different geographies. They happened to have the name of the systems they support, pinned to a board at their desks. The executive wanted us to take a picture of the two cubicles and email to him. We were quite surprised at the request. Before moving on to speak to other people he asked a couple of questions and realized the guys were sharing each other’s experiences and leveraging the lessons learnt from one deployment for the other geography.  It turned out that this does not happen in their organization, in fact their internal teams hardly communicate as they are part of different business units and geographies.

The story demonstrates how these organizations could become siloes due to distributed, outsourced and localized teams. Information Integration has become the way of life to connect numerous silos that are created in the process. Clinical research is a complex world.  While the players are limited, depending on the size of the organization and the distributed nature of the teams (including third parties), information silos and with that the complexity of integration of data increases. The result is very long cycle times from data “Capture” to “Submission”.

Clinical Data Integration Challenges

The challenges in integrating the clinical data sources are many. I will try to highlight some of the key ones here:

  • Study Data is Unique: depending on the complexity of the protocol, the design of the study, the data collected varies. This makes it difficult to create a standardized integration of data coming in from multiple sources.
  • Semantic Context: while the data collected could be similar, unless the context is understood, it is very hard to integrate the data, meaningfully. Hence, the integration process becomes complex as the semantics become a major part of the integration process.
  • Regulations and Compliance: Given the risks associated with clinical research, it is assumed that every phase of the data life should be auditable. This makes it very difficult to manage some of the integrations as it may involve complex transformations along the way.
  • Disparate Systems: IT systems used by sponsors, CROs and other parties could be different. This calls for extensive integration exercise, leading to large projects and in turn huge budgets.
  • Diverse Systems: IT systems used at each phase of the clinical data life cycle are different. This makes sense as the systems are usually meant to fulfill a specific business need. Even the functional organizations within a business unit will be organized to focus on a specific area of expertise. More often than not, these systems could be a combination of home grown and commercial off the shelf products from multiple vendors. Hence, the complexity of integrations increases.

What is Integration on the Cloud?

As mentioned earlier, integration is a complex process. As the cloud adoption increases, the data may be distributed across Public, Private (Includes On-Premise applications) and Hybrid clouds. The primary objective of integration on the cloud is to provide a software-as-a-service on the cloud to integrate diverse systems. This follows the same pattern as any other cloud services and delivers similar set of benefits as other cloud offerings.

The “Integration on Cloud” vendors typically offer three types of services:

  1. Out-of-Box Integrations: The vendor has pre-built some point-to-point integrations between some of the most used enterprise software systems in the market (like ERPs, CRMS etc.)
  2. Do-it-Yourself: The users have the freedom to design, build and operate their own integration process and orchestrations. The service provider may provide some professional services to support the users during the process.
  3. Managed Services: the vendor provides end-to-end development and support services

From a system design and architecture perspective, the vendors typically provide a web application to define the integration touch points and orchestrate the workflow that mimics a typical Extract-Transform-Load (ETL) process. It will have all the necessary plumbing required to ensure that the process defined is successfully executed.

Who are the players?

I thought it would be useful to look at some of the early movers in this space. The following is a list (not exhaustive and in no particular order, of course) of “Integration on Cloud” providers:

  1. Dell Boomi : Atom Sphere
  2. Informatica : Informatica CLOUD
  3. IBM : Cast Iron Cloud Integration
  4. Jitterbit : Enterprise Cloud Edition

These vendors have specific solution and service offerings. Most of them provide some out-of-the-box point-to-point integration of enterprise applications like ERPs, CRMs etc. They also offer custom integrations to accomplish data migration, data synchronization, data replication etc. One key aspect to look for is “Standards based Integration”. I will explain why that is important from a clinical data integration perspective later. While this offering is still in its infancy, there are some customers that use these services and some that are in the process of setting up some more.

Clinical Data Integration on Cloud

Many of you dealing with Clinical Data Integration may be wondering as to “Why bother with Integration on the Cloud?” while we have enough troubles in finding a viable solution in a much simpler environment. I have been either trying to create solutions and services to meet this requirement or trying to sell partner solutions to meet this requirement for the past 4 years. I will confess that it has been a challenge, not just for me but for the customers too. There are many reasons like, need to streamline the Clinical Data Life Cycle, Data Management Processes, retiring existing systems, bringing in new systems, organizational change etc. Not to mention the cost associated with it.

So, why do we need integration on the cloud? I firmly believe that if a solution provides the features and benefits listed below, the customers will be more than willing to give it a strong consideration (“If you build it, they will come”). As with all useful ideas in the past, this too will be adopted. So, what are the features that would make Clinical Data Integration on the cloud palatable?  The following are a few, but key ones:

  1. Configurable: Uniqueness of the studies makes every new data set coming in from partners unique. The semantics is also one of the key to integration. Hence, a system that makes it easier to configure the integrations, for literally every study, will be required.
  2. Standards: The key to solving integration problems (across systems or organizations), is reliance on standards. The standards proposed, and widely accepted by the industry (by bodies like CDISC, HL7 etc.) will reduce the complexity. Hence, the messaging across the touch points for integration on the cloud should rely heavily on standards.
  3. Regulatory Compliance and GCP: As highlighted earlier, Clinical Research is a highly regulated environment. Hence, compliance with regulations like 21 CFR Part 11 as well as adherence to Good Clinical Practices is a mandatory requirement.
  4. Authentication and Information Security: This would be one of key concerns from all the parties involved. Any compromise on this would not only mean loss of billions of dollars but also adverse impact on patients that could potentially benefit from the product being developed. Even PII data could be compromised, which will not be unacceptable
  5. Cost: Given the economically lean period for the pharma industry due to patent expiries and macro-economic situation, this would be a key factor in the decision making process. While the cloud service will inherently convert CapEx to OpEx and thus makes it more predictable, there will be pressure to keep the costs low for add-on services like “new study data” integration.

Conclusion

All in all, I would say that it is possible, technically and economically and also a step in the right direction to overcome some existing challenges. Will it happen tomorrow or in the next 1 year? My answer would be NO. In 2 to 3 years, probably YES. The key to making it happen is to try it on the cloud rather than on-premise. Some of the vendors offering Integration on Cloud could be made partners and solve this age old problem.

Update on 03/27/2012:

This post has been picked up by “Applied Clinical Trials Online” Magazine and posted on their blog -> here

Oracle launches Argus Safety 7.0…

Oracle released their latest version of Argus Safety Suite 7.0. The biggest highlight of this release is the “Multi-Tenancy”. This comes very handy for organizations that manage patient safety on behalf of more than one sponsor. This is being dubbed as a ‘CRO Release‘ for obvious reasons. However, another set of service providers that could benefit from this is the Technology Service Providers (TSPs).

Leveraging Argus 7.0, CRO and TSP organizations can host one instance of the application (not considering the various development, test, validation, training environments required) and provide technology and functional services to multiple organizations.  The software comes with all bells and whistles required for it to be regulatory compliant as well as keeps the data clean so there is no compromise of patient information and critical safety information. The biggest advantage is the feature set that will enable the CRO/TSP organizations manage the configuration required for each organization separate but at the same time enable them to be able to jump start a new organization’s configuration by leveraging configuration settings of an existing organization.

The diagram depicts a simplistic view of how this works. Please note that it does not include all the components of Argus system as well as the network elements required to ensure connectivity between the CRO/TSP to the sponsor organization. Essentially multiple sponsors will be able to connect to the Argus application through a custom/standard portal setup by the CRO/TSP.

Oracle Argus 7.0

Oracle's Argus 7.0 CRO/TSP Setup

In case of CROs, their internal staff viz. Admins, Data Entry, QA, and Medical Review personnel (depending on requested workflow by the sponsor or the CROs SOPs) would manage the cases. In case of TSPs, the Implementation (installation, configuration and support) and Hosting services could be provided by them while the sponsor manages the case processing bit.

Other enhancements to Argus Insight, Argus J and another new tool to manage Operational Analytics are slated for release throughout this year. In terms of upgrades, it comes with provision to upgrade from 6.0 and 6.0.1. However, for customers on prior versions, they would have to follow the step-by-step upgrade path till version 6 and then upgrade to 7.0.

If you need more details please write to me.

Changing role of CROs in Clinical Trials

Research Outsourcing:

Just like the Pharmaceutical and Biotech companies are realizing that IT services is a non-core activity that they tend to focus on due to growth of IT departments over a period of time. In this era of “Virtualized Everything”, outsourcing has become a common theme in IT for these organizations. Having said that, they typically outsource their R&D operations to specialized organizations like CROs.

IT Outsourcing by CROs:

CROs tend to provide mostly drug development activities, which include initiating and monitoring the clinical trials as well as providing the necessary IT backbone to manage data and documents created as part of this process. Because of renewed focus on core competencies, more and more CROs are looking for partners to outsource their IT systems and services. As a result of this, a new trend is emerging where in there would be two categories of CROs, Functional Service Providers (FSP) and Technology Service Providers (TSP).

Technically speaking, TSPs are not really CROs as they are not providing any clinical research services, however they are enabling the FSPs by providing the technology services required. The difference between your typical IT service provider and the TSP is that the TSPs should understand the Life Sciences domain. The primary reason for this is the regulatory compliance that is demanded by the Life Sciences industry in general.

Typical TSP Services:

So, what solutions and services do these TSPs provide? I think the following are some of the solutions and services these organizations can provide:

1. Technology Consulting

2. Tool Implementation and Support

3. Upgrades, Migrations & Integrations

4. Hosting Services

5. Computer System Validation

While the above mentioned services cuts across multiple areas within the clinical trial process, the question arises as to why would these organizations require domain knowledge?

Some additional functions that these teams can perform are:

1. Study setup in Clinical Data Management Systems and Clinical Trial Management Systems

2. Clinical Data Aggregation & Analytics

3. Safety & Pharmacovigilance System Setup

While the above mentioned are some high level activities, there would be always some grey areas where one would questions as to whether a specific service falls under a FSP or a TSP. For example, if you take designing CRFs, ideally you would want an FSP personnel to design these as they would understand the protocol easily and be able to translate that easily into the form design. Having said that, the CRFs also require some programming skills in which case you would need a TSP personnel. This is one of the ways a TSP differentiates from a regulat IT Service Provider.

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