This expansion of AERS, though, will not lead to any giant FDA health information database for postmarket surveillance. Instead,
FDA will expand its oversight capabilities by accessing data on drug use, patient outcomes, and specific safety issues held
by private health plans, database operators, government agencies, and manufacturers. The aim is to build a national, integrated,
electronic network for monitoring medical product safety through contracts and partnerships with these existing information
sources. By using a distributed network, all the personal medical data remains behind firewalls, reducing concerns about the
FDA compromising patient privacy and data security.
The FDA has been laying the foundation for the Sentinel System for years through such arrangements with healthcare "data owners"
that permit it to pose specific questions for evaluation through electronic health records, claims databases, and other information
sources. For example, the FDA has contracted for several years with UnitedHealth Group's Ingenix, Vanderbilt University, Kaiser
Foundation Research Institute, and Harvard Pilgrim Health Care to access pharmacoepidemiologic information that can test hypotheses
arising from AE reports.
The agency's Center for Biologics Evaluation and Research (CBER) works with the CDC, the Veterans Health Administration (VHA),
the Centers for Medicare and Medicaid Services (CMS), and large health plans to monitor influenza vaccine use and related
outcomes. A new CMS policy now gives FDA access to one billion pharmacy claims a year collected by the Part D Medicare drug-benefit
program, a treasure trove of pharmaceutical usage data. With additional funds to support postmarket safety surveillance, FDA
plans to expand its access to CMS, VHA, and health plan databases to further expand its ability to detect and assess adverse
events related to marketed therapies.
This distributed network system is expected to operate under a charter that defines which entities may join the public–private
partnership, what data sources will be used, what queries can be run on the system, who will be able to run queries, how specific
evaluations will be paid for, and how privacy protection will be ensured. A nonprofit network convener will channel information
and queries to the partnership and determine how results will be communicated to network participants and to the general public.
Many of these administrative and policy issues will be examined by an active surveillance pilot sponsored by the Pharmaceutical
Research and Manufacturers of America (PhRMA). After more than a year in development, the project is being launched as a public–private
partnership involving PhRMA, the FDA, and the Foundation for NIH, with Woodcock as chair. The aim is to test approaches for
organizing and operating a drug-safety query system using a distributed information network.
An important gain from a more efficient and proactive postmarket surveillance system will be to facilitate FDA approval of
new drug applications. If the regulators have confidence that safety problems will be identified more quickly and appropriately
after a drug goes to market, they may be more willing to approve a market application for a therapy that raises some risk
Biopharmaceutical manufacturers are nervous that earlier and broader assessment of postmarket data will yield false negatives
that set off alarms on every new product. But FDA officials believe that enhanced drug monitoring may even reduce the need
for some postmarketing studies. Instead of requiring manufacturers to sponsor a long list of postmarket clinical studies,
FDA reviewers may call for six months or a year of database monitoring for certain anticipated safety concerns. Expanded postmarket
assessment may put to rest concerns about the safety of a new drug or vaccine that are raised in prelicensure studies, observed
CBER Director Jesse Goodman; "The data can cut both ways."
Ultimately, it may be possible to monitor medical product safety through a national information network that connects clinicians,
consumers, and providers across the healthcare system. A linked system would provide a broader picture of health problems
and improve tracking of patients who shift healthcare providers, Woodcock commented at the Brookings forum. But that would
raise privacy issues and require a higher level of consent and transparency, she noted "We would not do this to start," she
said, "but we don't want to rule it out."
Effective communication about safety signals from interim results will be a challenge, as will efforts to provide adequate
and sustained financial support for what will be a costly undertaking. But these are issues that the FDA and its Sentinel
partners will address, as well as concerns related to scientific accuracy and data reliability, said von Eschenbach. FDA is
not implementing the Sentinel System "solely because Congress told us to, but because it's the right thing to do," he asserted.
"FDA must, will, and needs to do this."
Jill Wechsler is BioPharm International's Washington editor, Chevy Chase, MD, 301.656.4634, firstname.lastname@example.org