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  1. Advancing Regulatory Science

Source Data Capture from Electronic Health Records (EHRs): Using Standardized Clinical Research Data

CERSI Collaborators

Laura Esserman, MD, MBA, Adam Asare, PhD, Sue Dubman, University of California, San Francisco (UCSF)

FDA Collaborators

Mitra Rocca, Dipl. Inform. Med., Gideon (Scott) Gordon, PhD, Mary Ann Slack

Project Duration

October 2015 - October 2019

Regulatory Science Challenge

Clinical trials for new drugs require the collection of information and data about patients enrolled in the trials.  The information systems and the underlying data models and standards that define clinical care and regulated clinical research are highly variable.   This lack of uniformity was not an issue for the conduct of regulated clinical research prior to use of Electronic Health Records (EHRs) or Electronic Data Capture (EDCs), because data were captured on paper case report forms. However, much has changed in the past decade for regulated clinical research where EDC systems are now ubiquitous for the capture of clinical trials data. Similarly, EHRs and other Health Information Technology (Health IT) systems have been widely adopted and are rapidly becoming a standard part of clinical care. 

Project Description & Goals

The OneSource Project is a collaboration between investigators at the University of California San Francisco (UCSF)/Stanford Centers of Excellence in Regulatory Science and Innovation (CERSI) and FDA.  The goal of this project is to develop methods and tools to automate the flow of structured EHR data into external systems and thereby reduce operating costs, save time, and improve data quality for clinical trials. We have demonstrated an approach to transmit structured data from the UCSF EHR system to a clinical trial electronic data capture (EDC) system. In this approach, we populated Electronic Case Report Forms (eCRFs) for a phase II clinical trial, (Investigation of Serial Studies to Predict Your Therapeutic Response with Imaging And moLecular Analysis 2 (I-SPY 2 TRIAL)).

OneSource leverages standards from Health Level 7 (HL7), Clinical Data Interchange Standards Consortium (CDISC), and Integrating the Healthcare Enterprise (IHE) for the capture and transmission of clinical research data.  The goal of the work is to harmonize the data elements and use better tools for data capture that could make these key elements available for healthcare providers.  Electronic Patient Reported Outcomes (ePRO) was also implemented as part of OneSource for source data capture from patients in the I-SPY 2 TRIAL.

The electronic capture of data from EHRs and healthcare devices such as Electronic Patient-Reported Outcomes (ePRO) devices, digital imaging, and mobile health devices could improve the reliability, quality, traceability (provenance), and integrity of data from electronic source to regulatory submission.  In pursuing this goal, OneSource follows recommendations in two FDA guidances:

This project has been funded by the Patient-Centered Outcomes Research Trust Fund (PCORTF) investment opportunity through a competitive application process administered by the Office of the Assistant Secretary for Planning and Evaluation (ASPE), Department of Health and Human Services.

OneSource Report

Source Data Capture from Electronic Health Records (EHRs): Using Standardized Clinical Research Data (OneSource) Report (PDF-2MB) describes the development process and approach to electronic source implementation at UCSF. 

Related Resources

HHS ASPE PCORTF Portfolio of Projects

UCSF CERSI