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FDA “… recommends that clinical data be entered electronically by study site personnel at the time of the subject visit to avoid transcription from unnecessary paper records”1. The acronym “ALCOA” is frequently used in reference to best practices related to source documentation. When eSource solutions are selected and developed appropriately, data is attributable to a unique user with a secure password and role-specific privileges; legible in a clean and easy to read standardized format; and contemporaneous with a date and time stamp for every entry/edit/modification. Original records initially captured electronically can include direct entry of clinical data into a study database, data transmitted from an electronic health record, and electronic diary data entered by a subject or transmitted from an automated instrument that captures a biological result. eSource provides the opportunity to engineer accurate data with boundary and edit checks for missing and/or out of range data devoid of contradicting information often represented by subjective reporting in an unstructured format.
To minimize risks related to FDA requirements to keep accurate records and protect human subjects, sponsors using electronic source solutions should keep records of:
- system validation and maintenance,
- system specifications showing customization to fit the eSource for the purpose of the study,
- 21 CFR § 11 compliance and
- data integrity practices.
Ultimately, the same system development collaboration and documentation intended to manage risk, will have the added benefits of quality design, validated performance and accurate data capture with electronic efficiencies that reduce data noise, facilitate analysis and expedite time to data lock…and that’s what is best for patients.
1Guidance for Industry Electronic Source Documentation in Clinical Investigations Draft Guidance. U. S. Department of Health and Human Services, Food and Drug Administration, Office of the Commissioner. December 2010. Retrieved October 23, 2012 at http://www.fda.gov/downloads/Drugs/…/Guidances/UCM239052.pdf