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Institutional Review Board: Committee on the Use of Human Subjects

February 4, 2003

Dear Investigator:

RE: Request for IRB Approval for Chart Review

Retrospective chart review as a research methodology poses no more than minimal risk to subjects. Nonetheless, there is the possibility of a breach of confidentiality and as you are aware, privacy is a sensitive as well as legal issue at the current time. HIPAA regulations also require that we be protective of people's personal health information. In light of these concerns, the IRB is now requiring the following for all retrospective chart review studies:

1. A formal protocol with a statement of purpose, hypotheses or study question. This should be submitted on the Expedited Review Form.

2. On page 4 of the form, item #4, please include a detailed description of measures taken to protect confidentiality of data. Specify that data collection forms will be coded and not contain any personal identification; that the masterlist which links the subject's identity to the code will be maintained in a secure location; specify who has access to the list; that the list will be destroyed at the completion of the research.

3. Please attach a copy of the data collection tool you intend to use (Item 7, page 5 of form). If you are collecting any information which does not specifically address the study question, please add an explanation as to why the information is being recorded.

4. When applicable, please include a request for waiver of consent to participate in research and waiver of authorization to disclose and use Protected Health Information (PHI). Include the following justification:
a. the research involves no more than minimal risk to subjects;
b. the waiver will not adversely affect the rights and welfare of the subjects;
c. the research could not practicably be carried out without the waiver (cite protocol-specific reason);
d. the research could not practicably be carried out without use of the PHI;
e. written assurance that the PHI will not be reused or disclosed to a third party, except as specified by the Privacy Rule.

5. Prior to submitting an application, the investigator (including student researchers) should provide evidence of at least initial training for protection of human subjects in research. This requirement may be met by completing the computer-based program found on our website.

Please call if we may assist you in any way. Thank you for your cooperation.

Sincerely,

Ina M. Friedman, MSN, NP-C, CIM
Chair
Committee on Use of Human Subjects



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