By now the Coronvirus outbreak is affecting everyday life worldwide (see latest statistics Johns Hopkins University), and to avoid patient exposure or to reduce the burden on clinical services it also started impacting clinical trials; their execution, monitoring, and publications. Study staff re-allocated to clinical care or requested to stay at home, study participant enrolment and follow-up delayed to limit contact, and monitors being kept out of the hospitals.

With respect to clinical trial management more and more governmental guidance’s are safetyappearing in a hard to keep up pace, indicating what is the best approach with respect to study suspension, protocol amendments, deviations, and study participant recruitment and follow-up. Suggesting for example changing participant site visits to phone calls or paper questionnaires by post where possible, keeping in mind that study participant’s safety has the priority.

In this blog post I would like to address another tool at our disposal for monitoring: Remote (or centralized) monitoring, which depending on the local situation and study security arrangements can be extremely helpful to keep the ‘clinical motor running’ as far as possible given the current situation.


Besides training, Site File review, etc., one of the main reasons for the on-site monitoring is proper source data verification (SDV), i.e. the process to ensure that data are verifiable, correct, and complete. On-site monitoring, however, represents at least 15% of the total clinical study budget, and digitization and evolving regulatory insights nowadays allow for remote monitoring (remote evaluation carried out at a location other than the sites at which the clinical study is being conducted),  as well. Although remote monitoring may not be considered the tool of choice for your current clinical trial and/ or described in the study monitoring plan, in the current situation it may be the best tool we have, keeping in mind that remote monitoring is not the same as


although they do go hand-in-hand, because RBM allows for a lower than 100% SDV and it is extremely difficult to perform 100% SDV with remote monitoring and SDV (see below).

Key is to check whether your study allows for RBM, and what the monitoring plan says about remote monitoring. If it does include RBM, you may just need to adjust your timing or (temporarily) the degree with which you perform remote monitoring, or if it does not include RBM you may want to amend your monitoring plan, notify the applicable Ethics Committee on it (make sure to check their latest ‘Corona’ policy), and train your CRA’s. Especially do not forget the latter, since not all CRA’s are 100% familiar, yet, with remote monitoring procedures.

Good thing in this situation is that the


nowadays widely accept a risk-based approach for monitoring, and in parallel to the FDA, ICH-GCP, also the upcoming version of ISO 14155 allows for

“a combination of on-site and where justified, centralized monitoring, as appropriate”,

and see it as additional monitoring capabilities to complement or reduce the extend and frequency of on-site monitoring. So the ‘only’ thing to do is to ensure proper documentation and reporting to the applicable regulatory bodies (Competent Authorities as well as the Ethics Committees) of the ‘why and how’ to ensure you stay compliant with the applicable regulations.

While (temporarily) switching to remote monitoring, a few practical factors should be considered while performing remote monitoring, especially


The study sponsor (eCRF or alternative), but ideally also the concerning sites (electronic patient files), should have electronic systems in place that are remotely accessible in a secured way. Working with a paper study and study staff at home will make remote SDV virtually impossible.

Annet_MarjoleinFor proper SDV the CRA needs to be able to review the patient files. That tends to create challenges due to the fact that most of the hospitals in Europe do not allow for remote (so off-site) viewing of patient files by the sponsor due to (possible) data-protection issues, and in fact most of the Informed Consents does not include permission of sharing of personal not coded data outside the study site.

Since these limitations typically include blockage of web-based tools like WebEx, Skype, GoTo, etc., the best option we have in this respect is that study staff uploads critical coded reports into the study sponsor’s electronic system (eCRF or alternative) making it accessible to the CRA for review. The obvious down-sides being that this places yet a higher burden on the site study staff (so they should not be re-allocated to critical clinical care!), and this concerns a highly selective review. It would, however, to my opinion be the best option we have for the current situation besides suspending all activities, and is in line with a risk based approach with a reduced amount of SDV.


The regulations nowadays allow for combination of remote and on-site monitoring, and given the current situation it seems best to assess the situation for your clinical study, and (re) consider (temporarily) applying remote monitoring, while ensuring ongoing study participant’s safety and well-being, using a risk based approach for SDV.


Posted in Uncategorized | Tagged , , , , , , , , | 1 Comment



NCIARA-MDR etcothing could have been more illustrative for the medical device clinical trial environment in Europe  than the storms Ciara and Dennis in February. With BREXIT as a kick off, the Coronavirus spreading around te globe, the MDR deadline less than 3 months away, and a new version of ISO 14155 coming out shortly, 2020 for sure guarantees a stormy year for any-one involved in medical device clinical trials

Per 31-January BREXIT finally is a fact, but what that actually means for clinical trials with sites in the UK is unclear to say the least. Without any say from UK’s end, EU regulations such as GDPR and MDR still apply, at least for 2020, but at the same time MHRA published an updated guidance regarding medical device clinical investigations indicating that a clinical investigation of a non-CE-marked medical device should at least be considered for certain circumstances, and notification to the MHRA will not be required if the medical device to be used is CE marked for the purpose under investigation. This comes across as less stringent than the MDR, that says that for class III devices and implantable devices safety and performance data, as a general rule, should be sourced from clinical investigations, and that PMCF studies that involve

“submitting subjects to procedures additional to those performed under the normal conditions of use of the device and those additional procedures are invasive or burdensome, the sponsor shall notify the Member States concerned”

So, in 2020, should we or should we not follow MHRA guidance when a UK site is involved in our clinical investigation?

As if we did not already have enough challenges in the EU medical device environment, there the CORONAVIRUS (or COVID-19) appeared, originating in China and spreading across the globe by now. By the end of last month, it started affecting device availability at the hospitals, but by now it also has a direct effect on our clinical study work due to travel restrictions and hospitals starting to keep out clinical trial monitors. Making remote monitoring in spite of its down sides, all of a sudden a much more attractive option. But are your EU clinical study sites ready for that, and how does that work again with the GDPR?

MDR appliesIn the meantime, let’s not forget the MDR DEADLINE being right around the corner. With a substantially higher demand for qualitative clinical evidence, and, as a brief reminder, reasons for this include that:

  • existing clinical evaluations need re-assessment following limitations on equivalence, state of the art, as well as clinical data that are considered suitable,
  • several devices have been up-classified, and will require a more solid evidence base than before,
  • planned activities for Postmarket Clinical Follow-up will require actual data collection, and are no longer a paper exercise, and
  • clinical trial/ investigations supporting the regulatory files need to be conducted in compliance with the MDR and other Good Clinical Practices, such as ISO 14155.

So in short, due to a broader scope, better follow-up, as well as limitations on the use of existing clinical data, ‘the pressure is on’, especially for the clinical evaluations. The problem is, that when you do not have (access to) a lot of clinical data there is nothing to evaluate. I already see issues appearing with lower class devices that have been on the market for ages, but where complaint data and some publications from equivalent devices were considered insufficient under the MDD: Where does that leave us under the MDR?

So, and I cannot emphasize this enough, when in the fortunate situation that your device still has a valid CE mark, please make sure to pro-actively collect clinical data on safety and performance appropriate for your device and its intended purpose now.

The MDR mentions ISO 14155 as the GCP for medical devices, and the 2020 version will be coming out soon. An obvious attempt was made to align the two, but one should pay attention though, since their requirements with respect to clinical investigations are not 1:1. The MDR is, for example, more ‘lenient’ with respect to AE documentation, requiring recording of any AE

“identified in the clinical investigation plan as being critical to the evaluation of the results of that clinical investigation”,

whereas ISO 14155 requires all AEs to be documented. Furthermore, there are some nuances with respect to pre- and postmarket clinical studies. I will write a separate post on this topic soon, but when planning your clinical investigation make sure to know what bucket your medical device clinical trial belongs to, pre- or postmarket, interventional or observational, feasibility or regulatory, and what that means for the applicable rules.

In CONCLUSION, 2020 for sure is an exciting year for those in the medical device clinical trial environment and beyond, with a lot of question marks. Unsure what to do? Stay tuned and feel free reaching out for advice, ACS can help you finding the most cost-effective way for your device through this clinical evidence labyrinth.


Posted in Uncategorized | Tagged , , , , , , | Leave a comment


KlokUpdate 18-DEC-2019: The EU parliament adopted the second MDR corrigendum, giving manufacturers of Class I medical devices 4 years extra to bring their clinical evaluation in order, putting them in the same position as the other medical devices with a valid CE certificate.

With only half a year left until application, the implementation of EUDAMED delayed with 2 years, and slow progress on implementation of acts and guidances, there are calls for and rumors on extension of timelines of the EU MDR. But does that actually mean that medical device manufacturers have more time to bring their clinical evaluation in order?

Under the MDR all devices will require a Clinical Evaluation with clinical evidence

“appropriate in view of the characteristics of the device and its intended purpose”

including Class I devices.

Medical devices with valid CE certificates can be placed on the market under the current EU Directives as well as the new regulation during the transition period of the MDR. This means that CE certificates issued under the current Directives will remain valid for a period of four years post date of issue, so until 25th May 2024, unless there is a significant product update (then a clinical evaluation per MDR is needed).CE

Does that mean that for devices with a valid CE certificate there is plenty of time to update their clinical evaluation? The answer is that that depends on the device and the concerning clinical evaluation plan, since under the current directives manufacturers are required to actively update clinical evaluations

“.. when the manufacturer receives new information from PMS that has the potential to change the current evaluation; if no such information is received, then at least …. every 2 to 5 years if the device is not expected to carry significant risks and is well established”

so best case the manufacturer with devices in this category has time until the certificate expires.

LaidBackA laid back attitude towards product clinical evidence collection, however, is not advisable, since these manufacturers are in the fortunate situation they still have time to gather their own clinical evidence in a postmarket setting, which currently (changes are in progress everywhere though!) is still less complex than in a premarket setting, and might be a necessary evil since the equivalence pathway has become much harder under the MDR as technical, biological, and clinical

“characteristics shall be similar to such an extent that there would be no clinically significant difference in the clinical performance and safety of the device. Considerations of equivalence must always be based on proper scientific justification. Manufacturers must be able to clearly demonstrate that they have sufficient levels of access to the data on devices to which they are claiming equivalence in order to justify that claimed equivalence.”

More problematic is the situation for

class I medical devices since they have no CE certificate and will have to comply with the MDR and update all technical information including clinical evidence by May 26, 2020. Manufacturers of Class I devices may still self-certify, as long as MDR requirements are satisfactorily met, BUT an extra complicating factor is that several Class I devices have been up-classified to Class IIa, IIb or even Class III (including some health apps), SleepApnoeAppand the requirements with respect to pre- (and postmarket) clinical evidence are more strict under the current directives as well as the MDR.

Now, news is circulating for some time now that a second Corrigendum is in preparation, potentially introducing a transitional period for up-classified class l devices, including class I reusable devices, but, although projected for this month, thus-far unconfirmed as far as I am aware. So manufacturers better not bet on that, and, products with a valid CE certificate aside, all devices are still in the same boat as far as timelines for updating their clinical evaluation are concerned.

In conclusion, do medical device manufacturers have more time to update their clinical evaluation? Thus-far the answer is no, as nothing changed in that respect since the clarifying interpretation of the MCDG in beginning this year, and for the majority of devices the deadline of May 26th, 2020 still applies. So at this moment the key question is more whether 6 months will be enough to build or strengthen the clinical evidence base, if not already started working on it? For a full blown clinical investigation it typically will be too short (also refer to a previous post addressing time needed for a clinical trial), but when using alternative sources for your clinical evaluation it might just be tight, and key is to act NOW.

Feel free reaching out in case of questions regarding the above, or support needed concerning your clinical evaluation.


Posted in Uncategorized | Tagged , , , , , , , | 1 Comment


beach-landscape-sea-coast-water-rock-917958-pxhere.comThe medical device regulatory environment in Europe is moving, but not always as timely and as clear as one would wish, certainly not from clinical perspective. The

MDR/ IVDR Rolling plan

has been updated and mentions clinicals a few times, and I find the part on Eudamed stating that

“It is estimated that modules for clinical investigation and market surveillance might be only partly or not at all available at the time of application of the two Regulations (due to workability issues) but few months after.”

a little disturbing, especially as that will not only affect new clinical investigations, but also the ongoing studies: Among other things the MDR states that clinical trials that have started under the MDD prior to 26 May 2020 may continue, but also that reporting of serious adverse events and device deficiencies shall be done according the MDR. Meaning that from 26 May on these events need to be reported via Eudamed per Article 73 (e). So, althought progress has been made drafting the functional specs for Eudamed, I am not sure where this will lead us.

MDCG guidances

More MDCG guidance documents have been published and of particular interest from clinical perspective is the one on the clinical evaluation consultation procedure, with an (not legally binding) interpretation of the 3 criteria exempting devices from the clinical evaluation procedure with expert panels, and especially the one regarding

“new devices designed by modifying a device already marketed by the same manufacturer for the same intended purpose…”.

The interpretation is that “a device already marketed” cannot be intended to refer to a device already marketed uniquely under the new Regulation, and so, as Erik Vollebregt put it

“scrutiny is only for devices that are new at the time of the conformity assessment application for the MDR”,

which will be of great help trying to get some control over the workload of the expert panels.

And last there is the never ending story of the


Althought May is fighting it untill the bitter end, a no deal Brexit seems closer than ever, and the potential impact for those using or dealing with medical devices, and for UK patients requiring imaging and radiotherapy can be substantial.

Since UK Notified Bodies and competent authorities will no longer be recognized by the EU, medical devices and in-vitro diagnostics no longer can be brought to the EU market via UK: devices which enter the EU via or from the UK will be handled as import from a third country with all related consequences.

Patients with cancer in the UK are expected to face substantial challenges accessing the best care, as among other unfavorable developments, hospitals no longer carring out their own PET-CT services, deliveries of radiopharmaceuticals delayed and certain patients prioritised over others.

In conclusion,

the medical device environment in Europe is changing, with several moving parts and many uncertainties for manufacturers, users, and patients. We should keep in mind, thought, that most changes have been initiated for a better protection of patient safety.

Feel free reaching out to discuss any of the above or other aspects of the medical device clinical pathway in Europe.


Posted in Uncategorized | Tagged , , , , , , , , , , , | Leave a comment