数据采集和管理(说明:数据采集和管理由两部分组成,一为病例记录表(Case Record Form, CRF),二为电子采集和管理系统(Electronic Data Capture, EDC),如ResMan即为一种基于互联网的EDC:
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数据采集和管理
1.数据的可溯源性、电子病例报告表(eCRF)的填写与修改
电子病例报告表(eCRF)的数据均来源于原始病历,由研究者或者研究者指定人员填写,需确保信息的完整性和准确性。如果出现任何需要更正的错误,修改应按照eCRF填写说明进行规范操作,eCRF系统将自动记录数据修改者的姓名及修改日期。
eCRF填写完成后应及时通过网络提交至EDC系统,EDC系统中的数据经SDV,DM审核,质疑等处理确认无疑问后,在数据锁定前,研究者需要进行电子签名确认。
2.数据库的设计与建立
数据库由北京天创明达医药科技有限公司数据部门建立,应符合FDA 21 CFR Part 11的要求,数据库应对系统登录、数据录入、修改、删除等数据痕迹进行管理。
3.数据核查
数据核查包括系统程序核查(Edit Check),人工核查以及数据核查会议。eCRF中数据应当与源文件一致,如有不一致应由研究者作出解释。对eCRF中数据进行的任何更改或更正都应该有稽查轨迹(Audit Trail)。稽查轨迹应包括EDC中数据更改的日期、时间、更改人、更改原因、更改前数据值、更改后数据值。此稽查轨迹为系统保护,不允许任何人为的修改和编辑。稽查轨迹记录应存档并可查询。
4.质疑处理
数据录入并被储存在EDC系统之后,系统核查会启动运作并触发质疑,这些质疑需要研究者或其授权人员审核和回答。数据管理人员将会审核研究者的解答,如果回答可接受则会关闭该质疑。CRA/PM/DM/MM在数据审核过程中,如对数据有疑问,也可开启人工质疑;在数据更正或确认后,每个角色应关闭本角色开启的人工质疑。
通过编程产生受试者数据列表/报告以支持在整个研究过程中的人工数据核查。当出现需要研究者澄清/核实/确认的数据时,可在EDC系统中添加人工质疑。锁库前数据管理员要确认所有质疑都已解决。
5.数据库锁定
在数据审核并确认建立的数据库正确后,由数据管理人员、主要研究者、统计分析人员、申办者和监查管理人员共同对数据进行审核,并完成分析人群的最后定义及判断,之后由数据管理员对数据库进行锁定。
锁定后的数据库或文件一般情况下不得再做改动。如果数据库锁定后发现有数据问题,那么需要PM/DM/PI/Sponsor/SA多方共同讨论决定是否开库修改。重新锁定数据库的流程同首次锁库一致。
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Data collection and Management (A standard data collection and management system include a CRF and an electronic data capture:
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Data acquisition and management
1. Data traceability, electronic case report form (eCRF) filling and modification
The data on the Electronic Case Report Form (eCRF) are derived from the original medical records and are completed by the investigator or investigator designee to ensure the completeness and accuracy of the information. If there are any errors that need to be corrected, the modification shall be carried out in accordance with the eCRF filling instructions, and the eCRF system will automatically record the name of the person who modified the data and the date of the modification.
After completion of the eCRF filling, it should be submitted to the EDC system through the network in a timely manner. After the data in the EDC system is confirmed by SDV, DM review, questioning and other processing, researchers need to conduct electronic signature confirmation before data locking.
2. Database design and establishment
The database is established by the data department of Beijing Tianchuang Mingda Medical Technology Co., LTD., which shall comply with the requirements of FDA 21 CFR Part 11. The database shall manage data traces such as system login, data entry, modification and deletion.
3. Data verification
Data verification includes Edit Check, manual verification, and data verification meetings. The data in the eCRF should be consistent with the source document, and any inconsistency should be explained by the researcher. Any changes or corrections made to the data in the eCRF should have an Audit Trail. The audit trail shall include the date and time of the data change in the EDC, the person who changed it, the reason for the change, the data value before the change, and the data value after the change. This audit trail is system protected and does not allow any human modification or editing. Audit trail records shall be archived and searchable.
4. Challenge
After the data is entered and stored in the EDC system, the system check is activated and questions are raised, which need to be reviewed and answered by the investigator or his or her authorized personnel. The data manager will review the researcher's answer and, if the answer is acceptable, close the challenge. CRA/PM/DM/MM In the process of data review, if there is any doubt about the data, it can also open a manual question; After data correction or confirmation, each role should turn off the human challenge that its role has enabled.
Subject data lists/reports are programmed to support manual data verification throughout the study. A human challenge can be added to the EDC system when data arises that requires clarification/verification/confirmation by the researcher. The data administrator needs to confirm that all challenges have been resolved before locking the library.
5. The database is locked
After data review and confirmation that the established database is correct, the data manager, the main researcher, the statistical analyst, the sponsor and the monitoring manager jointly review the data, and complete the final definition and judgment of the analysis group, and then the data manager locks the database.
Generally, a locked database or file cannot be modified. If data problems are found after database locking, PM/DM/PI/Sponsor/SA parties need to discuss together to decide whether to open and modify the database. The procedure for relocking a database is the same as that for locking a database for the first time.
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