eTMF Automation Strategies

Over the past 10 years, the Clinical Trial Master File, or TMF, has evolved into a powerful and digital “single record of truth” known as the eTMF. This evolution of the eTMF was driven by the industry’s practical need to digitize all the essential documents of a clinical trial. 

An eTMF itself is not an automation solution for managing essential documents. Think of eTMF as a highly organized electronic file cabinet. Even if you assign users rights to upload, approve or reject document versions, essential document workflow is still missing. Most eTMFs cannot track a document’s history, its edits or any collaboration around each document. That leaves the entire essential document workflow in manual mode without an automation solution.

Why is eTMF Automation Important?

eTMF automation represents an opportunity to cut millions of dollars in expense while ensuring that clinical trial regulations are followed with technological precision. When we talk about eTMF automation, we are talking about automating all the manual processes that move essential documents back and forth from the first site startup of a trial until the study is closed. eTMF automation must support digital document exchanges between the trial sponsor and the trial investigators. 

eTMF automation workflow begins with a premise that there shall never be more than one copy of a document, regardless of the status of a document, or the number of collaborators that are involved. In an automated workflow, documents are not downloaded or uploaded by users. Instead, users work together in an online portal designed for clinical trial collaboration. 

Automation improves trial speed, CRA productivity, site satisfaction, and provides a perfect audit trail of documents on their way into the eTMF. Automation also enables sites and sponsors to fulfill regulatory requirements that require sites to maintain their own TMF that mirrors the sponsor’s eTMF but keeps patient data hidden from the sponsor. 

A typical study can involve millions of documents, hundreds of sites, weeks of collaboration, multiple revisions, eSignatures, wet signatures, complicated regulatory requirements, and many associates to manage the tons of paper that all end up in your eTMF. None of these processes require paper documents in today’s world.

4 Strategies to Automate your eTMF

There are 4 possible strategies you can consider to automate the complex and essential document workflow of a clinical trial. 

  1. Wait and see if your eTMF vendor develops an automation product in the future
  1. Build in-house software customized to meet your company’s specific needs
  1. Contract with a large consulting company to lead the project and develop a solution
  1. Organize a project team to evaluate commercial software solutions

The Wait and See Strategy: Waiting to see if new automation solutions are delivered by your eTMF vendor will protect you from making a wrong automation decision today, but it won’t help you solve challenging compliance hurdles that are trending toward more auditing of essential document compliance in eTMFs and ITMFs.

The Build In-house Strategy: Building in-house software has some advantages, including more control over the software requirements and eventual ownership of a finished system without depending on a software vendor. But a disadvantage to this approach is that it could end up costing more money than commercial software and not provide the same product maturity a commercial product can provide.

The Consultant Strategy: This approach is most effective when your goal is to transform your business processes and redeploy human capital to become more productive and therefore more competitive.  Consultants offer their clients the opportunity to rethink organizing people and processes. They are capable of making recommendations that should put your company on par or ahead of the competition. On the other hand, over the last decade, the number of consulting companies that specialize in creating software solutions for their clients has declined. More often than not, the technical and business challenges of a large company are mature and need only a little fine-tuning, not reengineering. Licensing commercial software has become a standard approach as companies try to avoid “reinventing the wheel”.

The Commercial Software Strategy: Organizing a team to evaluate commercial software solutions is a great strategy for multiple reasons. By watching a demonstration of commercial software designed to support eTMF automation, you gain insight into the dozens of ideas that other clinical trial sponsors have added to that product over the years. Additionally, you can view commercial software as a viable alternative to any other strategy. Look for a product that can save your organization money, improve your service level to sites, and always allow documents to be audit ready. 

What Exactly Gets Automated?

Specific regulatory requirements must be adhered to during a clinical trial and essential document requirements can get complicated. An eTMF automation product must at a minimum automate the following document processes:

  • Assemble and distribute the correct study startup package to each site, regardless of country, language, or local requirements.
  • Support each document’s essential workflow requirement without the need to download or print any required document.
  • Create a clinical site TMF that mirrors the sponsor’s eTMF and protects private patient data from being reported to the sponsor.
  • Distribute safety reports to every applicable trial site, collecting acknowledgement electronic signatures from those sites where it is required
  • Replace the current trial Protocol with an amended protocol document, collecting acknowledgement statements from every site.
  • Convert a site’s paper documents with wet signatures into digital documents without the need for a scanner.

Conclusion 

Each essential document has specific requirements for sending, receiving, acknowledging, collaborating, signing and storing. Moving those documents back and forth using postal mail, fax machines, or email messages is not automation. No matter how efficient your manual processes might be, in a manual system of SOPs, it requires a lot of human effort to keep essential documents organized and moving forward during a trial. Time, money and frustrated clinical sites make manual processes undesirable in a modern clinical trial.

InnovoCommerce has worked with several of the top 10 pharmaceutical companies for the past 7 years to design and build a commercial software solution that fulfills all the requirements of eTMF automation. Our product, the Study Collaboration Portal, plugs into any commercial eTMF system, and gives it the power it needs to automate its essential document workflow. Regardless of which strategy you choose to automate your eTMF, a deep dive into our commercial software will give your team the clarity they need to make an eTMF automation decision.

Top 10 Reasons to Automate your eTMF

Novo Nordisk and Boehringer Ingelheim have automated the distribution and collection of regulatory documents from study startup to study closeout. We asked both companies to make the business case for paperless essential document workflow. Their feedback inspired this article: “The Top 10 Reasons to Automate Your Essential Documents.” 

(Both Novo Nordisk and Boehringer Ingelheim use software from InnovoCommerce to automate their regulatory document workflow) 

#1 – Update study documents faster 

It is always faster to update a digital document than a paper document. Consider the time it takes to print an update to a study protocol, insert the update into the protocol while archiving the old version, and documenting those changes in an audit trail. Sponsor study teams and site staff could spend an hour on a task that would have taken 10 seconds in a paperless trial. Keep in mind that in this example, over the course of a Study, the Protocol gets amended multiple times. So, going paperless has an absolute speed advantage over paper. 

#2 – Retire old document versions automatically 

When you hold two paper versions of the same document in your hand, it can be difficult to identify which document includes the latest changes. During a clinical trial, paperless systems retire old documents as the new document versions are published, so you never have to discern which document is the newest version. Paperless binders at a trial site are always up to date. This simplifies CRA monitoring visits since there is no need to review a traditional paper binder during their routine site visit. 

#3 – Harmonize the document distribution process 

The success of paper processes is highly dependent on people to stay organized. The standard operating procedure for one site could be vastly different at other sites. Additionally, the sense of urgency to keep paper processes moving along varies from site to site. When automated processes are put in place, they keep things moving along according to a unified process configured in the software system itself. 

#4 – Speed up Study Start-up at every site 

The fact is, study documents are complicated. Paper complicates distribution because paper moves slowly. And preparing a paper package requires meticulous attention to detail, reviews by individuals, and finally some form of shipping and receiving. For the study site, paper is received with all the other paper that is used to run a business and is processed as time permits when patients are not waiting in the lobby. But electronic study documents move at light speed and are always in a highly organized state, dictated by the workflow of the software system that moves the documents along. This shortens the time for starting up the study at the sites, and site staff have more time to focus on patient recruitment and care. 

#5 – Decouple document collection from site monitoring 

Unlike paper documents, electronic document distribution and collection is decoupled from site monitoring. Using an electronic study document exchange system, the status of each document is always known. There is no reason to call or visit the site to check the status of a document or to make sure the site has filed all the paper artifacts correctly.  This saves time not only for monitors, but also for the busy study site staff.

#6 – Find every document in one place 

The world of paper is a complex set of processes and places. Most of these processes have to do with moving the paper and most of the places are ad hoc repositories (for example an email in-box), until eventually every paper document ends up in the correct place. Electronic systems move the study documents using workflows and keep every document in the same repository while moving the document through each stage using distribution requirements. This gives sponsors a huge cost savings while ensuring there is only one record of truth pertaining to all regulatory study documents.  

#7 – Improve site satisfaction in a big way 

By any measure, the elimination of paper at sites increases site satisfaction. Sites that use electronic systems provided by the sponsor or CRO never need to wonder what actions are needed by the sponsor, CRO or the site staff. Tasks are presented at the correct time and when action is required (like acknowledge or sign). Site staff is never asked to move regulatory documents from one place to another. They never need to print a document to sign it, and they never need to file a document since all of this happens automatically in an essential document shared system.  

#8 – Reduce time required for Quality Assurance 

In a paperless system, documents are distributed, edited, and collected within the system, creating an indisputable audit trail. The dates, times, user identity, and various metadata of a document are recorded and updated automatically. This removes a significant QA burden by eliminating some QA checkpoints, and enables the quality assurance staff to review and approve hundreds more documents each day.

#9 – Achieve a contemporaneous eTMF 

The reason ICH introduced the concept of contemporaneousness is that in the past, many paper artifacts were found to contain curious details. For example, a signed document that shows the signer’s receipt date is later than the signers signature date. Paper-based processes are often paused for any number of reasons that have nothing to do with the clinical trial, leaving staff to try and catch up on work by signing with dates that “should” have been met. This can result in a sloppy TMF and could give regulatory inspectors a reason to look further into a trial’s accuracy.

#10 – Solve the completeness challenge 

The biggest challenge to maintaining a state of completeness during a study can be managing paper documents. Paper by its very nature is an offline product that exists outside of the clinical trial itself. As the sites get added to the trial or removed from the trial, the complexity of tracking documents increases substantially. TMF managers even create “place holders” in their eTMF for paper documents they expect to receive, and then run reports showing the place holders so they can contact sites to request the missing documents. In a properly designed electronic system, the expected count of the study documents based on currently active sites is always known along with the actual completion status of the document at any point in time. The completeness challenge is solved because documents are never lost, delayed, or missing. As soon as a document is signed, it appears in the QC work area, ready for inclusion in your eTMF. 

Conclusion 

The transformation from a paper-based system to a paperless model in clinical trials is a goal at many clinical sponsors and research organizations. Connecting your eTMF to a clinical trial automation product is key to this transformation. The software product that helped achieve this goal at Novo Nordisk and Boehringer Ingelheim is the Study Collaboration Portal and can be further researched at www.innovocommerce.com 

eTMF Automation – FAQ

Frequently Asked Questions about eTMF Automation

How can we truly go paperless if trial sites prefer wet signatures?

The short answer is that you don’t have to force sites to go paperless. We have found that tens of thousands of users at sites using our Study Collaboration Portal software were thrilled to go paperless, including eSignature, once they logged in to the portal and saw that it supported both wet signature and eSignature.

There is always a bit of cultural change required when technology advances. But in this case, our customers learned sites become the biggest advocates once they experience how much time can be saved by moving away from wet signatures. However, when sites do execute wet signatures, our software sends that document with its wet signature into a special QC check. Once the wet signature is approved, that document and its wet signature continue to move along as a paperless document.

Do you have any stats on how long it takes for a document in your system to go from site collaboration and collection to eTMF?

During paper-based trials, essential documents can take 40 to 60 days from scan until final QC check, prior to adding them to your eTMF system. Our Study Collaboration Portal solution eliminates all the paper-based steps, including printing, signing, scanning, and scan inspections. That means when a document is distributed by our system, depending on whether or not it needs a signature, the document is ready for a final QC immediately or upon eSignature a few days later. This process includes the documents collected from the Sites. The eTMF can receive documents immediately after a single QC review. Timeliness and contemporaneousness become the default status of your eTMF.

How much time does a CRA need to spend in your system to review the site binder during a monitoring visit?

Because Study Collaboration Portal is automated and paperless, completeness is decoupled from site monitoring visits. There is never a reason to check the binder at a site because the binder can no longer be out of order, it wont be missing an artifact, and it can’t contain an outdated document. Site Binders are always in a state of completeness.

If a site needs to sign or acknowledge anything, the sponsor is already aware of the missing signature or acknowledgment without a site visit. And the site is aware of their incomplete task because it is the first thing they see when they log in. For these reasons, CRAs can spend time at the sites doing more productive things than reviewing paper binders.

Does your system send out a lot of emails to sites? Don’t paperless systems send out way too many reminders upon reminders?

Our customers usually set up Study Collaboration Portal to send once per week digest emails that contain clickable links to any actions that need to be taken care of. This strategy not only solves the issue of getting too much email, but it also gives sites a chance to get their work done without getting reminders from a system that doesn’t know whether the site already took care of a task. When we launched “Digest” messaging in version 6 of the Study Collaboration Portal, our site user productivity increased, and task cycle time dropped. It is a good balance between harping on users and helping users complete their work.

Study Startup has a lot of sub-processes. How does your software deal deal with the complexity of distributing and collecting the variety of startup documents?

A recent ACRP article on study startup said it best, “a large chunk of start-up effort is spent on coordinating the essential document compilation, review and reconciliation steps required for various submission packages”. Automating startup essential document workflow is complicated because there are 8 different essential workflows in every study and a study startup package contains at least 4 of them.

This is exactly where Study Collaboration Portal provides maximum benefit and efficiency. Our purpose built workflows are automated and they require no configuration as they route correctly, right out of the box. From trial start to trial finish, Study Collaboration Portal eliminates the study startup paper ISF, and manages a paperless compilation and automated distribution of the package as it tracks the package status in real-time until completed.

How can we effectively track and approve the Informed Consent that is being edited by the site prior to site startup?

The collaboration workflow built into the Study Collaboration Portal enables the site to edit the Informed Consent provided by the sponsor and send it back to the sponsor for approval. The sponsor can provide feedback or approve the document. Once the document is approved, it is locked and cannot be edited. The site can then submit the document for IRB/EC approval, provide IRB/EC feedback to sponsor and finally upload the IRB/EC approval letter back to Study Collaboration Portal. All versions of the Informed Consent along with changes made at every stage are maintained in an audit trail.

How do you handle the Closeout document collection process?

During the closeout process, all study files are reconciled with the Trial Master File. This used to be a painstaking and time-consuming process. However, Study Collaboration Portal has completely automated this process by designing a system that keeps essential documents validated at all times and transferred to the eTMF for QC in real-time. However, any missing document, such as study team licenses, CV’s, laboratory documentation, etc. will be available as an open task for the site to complete.

The CRA can simply monitor everything remotely during the trial to ensure the site completes all required documentation in a timely manner, long before closeout. Once a site’s role in the trial is complete, the sponsor has the ability, in one click, to archive all documents and communication provided to the site during the conduct of the study and provide that archive to the site. All documents and correspondence are automatically converted to PDF for long term retention by the site.

Why should I consider InnovoCommerce over [fill-in-the-blank]?

We don’t mess around when it comes to designing and building great software. We have been delivering enterprise scale software for drug safety, device complaint handling and clinical trials since 1995. Our team envisioned the Argus Safety product in 1996 and launched it to the world in 1998. (At a time when there were many other companies already offering software for adverse event handling.)

Today, Study Collaboration Portal is the only commercial software to deliver end-to-end automation of regulatory document distribution and exchange from study startup to study close out. Our customers are years ahead of their competition by using our product.

You can count on us to deliver a scalable enterprise solution to your trial document challenge, You don’t have to build your own. Contact us for a demonstration today.

Can you validate our installation?

Sure can! We can provide a spectrum of go-live support from supplying baseline validation templates to designing and executing your validation scripts for you. Every deployment starts with a set of project templates and other standard artifacts like administration guides, validation guides, and a functional design specification. Then we work with customers through pilots to identify gaps and find what they need to get the system up and running. Contact us for more information on deploying SCP at your organization..

The Fully Wired SUSAR

How to save millions of dollars during clinical studies by automating SUSAR distribution

Boehringer Ingelheim (BI) is one of the largest pharmaceutical companies in the world, and has lead the way in study treatments and cures in the areas of cardiovascular, oncology, respiratory, central nervous system, immunology and metabolic diseases.

BI conducts clinical trials to determine the safety and efficacy of its drug candidates. Real-world data gathered during a clinical trial is studied to determine whether a candidate drug merits further study and, eventually, whether the drug should be submitted to regulatory agencies in a new drug application (NDA).

Like every other pharmaceutical company, BI has either developed in-house software solutions or adopted commercial software solutions to improve both the speed and accuracy of every clinical trial. Without question, software plays a mission critical role in the effort to improve the conduct of clinic trials and ultimately to improve human health around the world.

While there have been industry-wide improvements in electronic data capture (EDC) and electronic trial master file (eTMF) technology, little has been done to improve the flow of essential documents during the study itself. During a clinical trial, essential documents move back and forth between trial sponsors, clinical research organizations, investigational review boards, clinical sites, investigators, patients, ethics committees and regulatory agencies. 

Depending on the type of document, it may require edits, collaboration, signatures, acknowledgments, timely distribution and even mandated distribution timelines. That amounts to a high number of documents, distributions, and people involved, so companies need to rely on efficient and reliable systems. 

The essential documents of any clinical trial are specified by the ICH (International Council on Harmonization) as mandatory to good clinical practices. While ICH guidelines describe more than 50 essential document types, the majority of clinical trials involve more than 100 essential document types. 

Over the course of a clinical trial, hundreds of thousands of interactions with essential documents take place. The numbers are so vast that sponsors of large trials spend hundreds of thousands of man hours sending, receiving documents, editing, signing, approving, reviewing and storing essential documents. The human effort spent managing essential documents during a trial adds millions of dollars in cost to each and every clinical trial.

One type of essential document is the Suspected Unexpected Serious Adverse Reaction, or SUSAR. Each SUSAR report identifies a single patient’s unexpected and serious reaction to a drug being studied. 

Depending on the severity of the reaction, a SUSAR report must be sent to regulatory agencies 7 to 15 days. In addition to agency reporting requirements, some countries require SUSARs to be shared with investigators studying the same drug, regardless of whether that investigator is involved in the same clinical trial. The sooner this information can be distributed to each clinical site investigating the drug in question, the sooner a decision can be made whether to continue investigating a drug, whether a particular patient should receive the drug, or whether one patient type seems to be more susceptible to side effects than another patient type. It is worth noting that reporting these events to principle investigators at clinical sites can be a matter of life and death for patients.

The BI team was also interested in the possibility of electronically distributing all SUSARs involving a drug under study to all sites conducting a study of the same drug. In the previous paper-based process, such wide distribution would have been impractical and even confusing to some investigators. BI determined that by using technology to automate the distribution of SUSARs, it could improve its own efficiency in reporting SUSARs to sites.

Considering the complexity of global and local regulations, short reporting deadlines, as well as the legal requirement to add previously unlisted adverse events to revisions of the Investigator Brochure (IB), there were many challenges to overcome in SUSAR distribution.

BI created an internal team to implement a change management process that would allow it to migrate from a paper-based workflow to an automated workflow. This change would reduce the workload on local affiliates and clinical sites by using the advanced workflow and distribution capability available in the InvestigatorFIRST™ software product. In doing so, BI were aiming to achieve timely service levels, oversight, and efficiency, while supporting further automation in the future.

Keeping in mind the goals of the project, BI configured the InvestigatorFIRST™ Study Collaboration Portal™ to mirror the ideal SUSAR workflow identified in the change management process workshops held by BI.  Special configurations based on geography were categorized into IND Countries, expedited SUSAR countries and countries where distribution is restricted if the event origin is in the same country. 

The process was simplified to achieve full transparency with the guiding principle that each investigator should get the same set of safety information. This meant that some Investigators in some countries would receive more SUSARs than regulatory agencies require. Because the Study Collaboration Portal™ could self-organized all SUSARs, it was determined that investigators would not be burdened by a more complete SUSAR distribution.

Enabling centralized distribution of all SUSARs to all applicable investigators at all applicable sites dramatically improves an investigators ability to gain insight into the safety of a particular drug for a particular patient.

Quality checks were also added at various workflow steps to ensure that all received reports (from the pharmacovigilance team) are actually distributed, the assigned drug and the target audience matched, and cross reporting rules are consistently followed by the software.

The final distribution logic configured in the software workflow was implemented with an appropriate notification period to users. A dedicated audit role created in the Study Collaboration Portal™ allowed BI to conduct real-time compliance tracking to support oversight of distribution timelines.

The system was also configured to automatically distribute all other study safety documents including: Periodic Safety Reports, Dear Investigator Letters, Startup of Safety Report Distribution Letters, Expedited SUSARs, Expedited SUSAR Translations, SAEs, and SESARs (Suspected Expected Serious Adverse Report).

During the four year period since BI implemented the InvestigatorFIRST™ Study Collaboration Portal™, the automated SUSAR workflow has governed each of its clinical trials and based on each drug under investigation, every investigator has received the appropriate safety information during a clinical trial, achieving the goal of a harmonized process capable of handling exception scenarios. The process was also demonstrated in detail to the US FDA during a meeting with BI’s global pharmacovigilance team. 

Not only have compliance timelines been consistently met since adding SUSAR distribution to BI’s Study Collaboration Portal™, but many productivity gains have been achieved, including all received reports being distributed without manual processes, assigned program and target audiences are always correct, cross reporting rules are automatically followed, and every trial is inspection ready at all times.

By any measure, BI’s Study Collaboration Platform™ developed by Innovo Commerce has been a runaway success for Boehringer Ingelheim. 

Not only is regulatory compliance achieved in real-time, productivity gains can be measured in hundreds of thousands of man hours per year. The Study Collaboration Portal™ has been in place for four years and has been credited with saving BI tens of millions of dollars each year. 

Today, all clinical trials are conducted in an advanced state of completeness employees and other associates of BI are more productive and no longer spend countless hours distributing tens of thousands of documents of all kinds throughout each clinical trial.